Challenges and pitfalls of extracorporeal membrane oxygenation in critically-ill pregnant and peripartum women with COVID-19: a retrospective case series

BACKGROUND: Available data identify pregnancy as a strong determinant of a severe course of COVID-19 with increased mortality. Extracorporeal membrane oxygenation (ECMO) remains the last resort treatment in the critical course of COVID-19 yet may increase the risk of excessive bleeding, especially in the immediate post-cesarean section period. One in five patients receiving ECMO during the COVID-19 pandemic were women who were pregnant or postpartum. While the risk of critical respiratory failure in the peripartum period is high, in an early survey only 52% of pregnant patients intended to receive the COVID-19 vaccine. METHODS: Our study aimed to evaluate clinical characteristics and treatment modalities in a series of five pregnant and peripartum women supported with ECMO and anticoagulated with anti-Xa-guided nadroparin therapy in our center. We reviewed the full treatment courses; inflammatory, hemodynamic, and coagulation variables; and maternal and neonatal outcomes. We identified adverse events during the therapy. RESULTS: All five patients developed acute respiratory distress syndrome due to COVID-19 in the third trimester of pregnancy. Termination of pregnancy occurred between 28 and 36 gestational weeks. While four of five newborns survived to hospital discharge, only two of the five mothers survived to leave hospital. CONCLUSIONS: ECMO is feasible in the third trimester but not devoid of complications. The severity of respiratory failure during COVID-19 and extracorporeal support may not adversely impact neonatal outcomes.