DP43: SUCCESSFUL MANAGEMENT OF SEVERE ARDS IN A MORBIDLY OBESE PARTURIENT REQUIRING EMERGENCY CAESAREAN SECTION USING ECMO: A CASE REPORT
Sindhura Sharma Bhat, MD; Sandy Ren, MD; Cosmin Guta, MD; Mathias Bruefach, MD
University of Miami / Jackson Memorial Hospital
Introduction: Acute respiratory distress syndrome is an uncommon but serious entity in the obstetric population associated with a high incidence of complications in the third trimester. When conventional therapies including mechanical ventilation, pharmacologic interventions, and prone position fail, extracorporeal membrane oxygenation (ECMO) may serve as a life-saving intervention. However, data on ECMO use in late pregnancy are limited, necessitating careful evaluation of risks and benefits.
Case Report: We report the case of a 34-year-old African American female at 37.0wks gestation with past medical history of morbid obesity (BMI of > 65), asthma, gestational diabetes, anemia, active influenza A complicated by severe ARDS requiring intubation. Despite optimized mechanical ventilation, neuromuscular blockade, and iNO at 40 ppm; patient’s P/F ratio remained less than 100. The multidisciplinary team decided for a stat caesarean section (c-section) with the plan for veno-venous (VV) ECMO after delivery; however, patient decompensated on arrival to the operating room with an spO2 of 12%, and VV ECMO had to be initiated prior to starting the c-section. Cannulation was performed without complications, leading to stabilization of maternal hemodynamics and the baby was delivered via c-section. ECMO support was discontinued 8 days postpartum, and the patient was successfully discharged home thereafter.
Discussion: The application of ECMO in pregnant patients with refractory ARDS has shown promising outcomes. Pacheco and Shamshirsaz (2023) highlighted the increasing role of ECMO in maternal survival with minimal fetal risk when managed in specialized centers. A systematic review by Sebastian et al. (2022) reported maternal survival rates of 75.4% and fetal survival rates of 64.7% in pregnant and postpartum patients undergoing ECMO. Additionally, Duarte (2014) emphasized the importance of early recognition and aggressive management of ARDS in pregnancy to improve outcomes.
Recent meta-analyses have further supported the use of ECMO in this population. A study analyzing pregnant women with ARDS secondary to COVID-19 reported a maternal survival rate of 75.6% and a live-birth rate of 83.7% among those managed with ECMO. These findings underscore the potential of ECMO as a viable intervention in severe ARDS cases unresponsive to conventional treatments during pregnancy.
The decision to employ ECMO necessitates a multidisciplinary approach, involving obstetricians, intensivists, neonatologists, and ECMO specialists, to balance maternal and fetal risks and benefits. While prone positioning is a recognized therapy for ARDS, its use in late pregnancy is limited due to anatomical and safety concerns. In our case, ECMO provided adequate gas exchange, allowing for maternal recovery and favorable neonatal outcomes.
Conclusion: This case illustrates the successful use of ECMO in managing severe ARDS in a third-trimester pregnant patient unresponsive to standard therapies. With careful patient selection and a coordinated multidisciplinary approach, ECMO can be a life-saving intervention, leading to positive outcomes for both mother and child. Further research and development of standardized protocols are essential to optimize the management of similar cases in this unique patient population.