Guideline on pregnant and peripartum extracorporeal membrane oxigenation, Elso 2025 Narrative

At the time of publication of this guideline, the leading causes of maternal death for pregnant and peripartum patients include hemorrhage, infection, eclampsia, thromboembolism, and cardiac disease.^1–3 Not only are these causes of death preventable, but they have also been successfully supported with extracorporeal membrane oxygenation (ECMO).^4–8 In fact, survival for peripartum patients supported on ECMO is higher than any other population supported on ECMO.⁹ Physiologic changes, such as impaired right atrial venous return and hypercoagulability, however, make ECMO support in these patients complicated.^10–12 Specific guidance for the successful support of these patients using ECMO is lacking. The Extracorporeal Life Support Organization (ELSO), with subject matter experts, performed a literature search, screening 378 articles, fully reading 98 manuscripts, and narrowing the references down to 87 publications to guide ECMO use in pregnant and peripartum patients. A summary of our recommendations can be found in Table 1.

Extracorporeal membrane oxygenation indications during pregnancy and peripartum are most commonly the same as in other populations, however, there are pregnancy-specific indications. Published reports quote ECMO in refractory acute respiratory distress syndrome (ARDS) and respiratory failure as the most common indication for peripartum ECMO, seen in 50% of peripartum cases, followed by cardiogenic shock in one-third and extracorporeal cardiopulmonary resuscitation (CPR) in about 18%.^4,9 Bacterial and viral pneumonia, such as H1N1 and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), leading to ARDS are typical indications.^9,13,14 Pre-eclampsia and eclampsia, hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome are specific disorders of pregnancy and peripartum period and indications for venovenous (VV) ECMO.^4,9 Pulmonary embolism is a leading cause of maternal morbidity and mortality, and ECMO can provide cardiovascular rescue in such cases.⁴ The relatively uncommon amniotic fluid embolism is associated with very high maternal mortality, and venoarterial (VA) ECMO has been used with variable degrees of success.¹² Peripartum cardiomyopathy or worsening of pre-pregnancy cardiac disease are indications for VA ECMO.^4,9,15 Indications for ECMO in obstetric patients are listed in Figure 1.