Amniotic fluid embolism (AFE) is a potentially lethal complication of pregnancy that results from disruption of the maternal–fetal interface and occurs as frequently as one in every 8,000 deliveries.¹ When AFE is complicated by cardiovascular collapse, the Society of Maternal-Fetal Medicine (SMFM) recommends against routine use of veno-arterial extracorporeal membrane oxygenation (V-A ECMO) in AFE due to a lack of robust evidence of benefit and the potential risk for anticoagulation to worsen bleeding in patients with coagulopathy.²

Despite advances in maternal mortality in the 20th century, since 2000, maternal mortality has been rising.³ The outcomes of AFE are frequently catastrophic, with coagulopathy, respiratory failure, and cardiac arrest being common. Historically, the mortality rate for AFE was as high as 86%, whereas contemporary data show mortality from 13% to 23%.¹

Early V-A ECMO centrifugal pumps and oxygenators caused significant blood trauma. Since the mid-2000s, improved pump and oxygenator technology has lowered bleeding complications and allowed V-A ECMO without systemic anticoagulation, renewing interest in extracorporeal support in AFE.^4,5 To estimate the survival rate and complications of AFE patients undergoing V-A ECMO, we assessed the outcomes of all cases of AFE managed with V-A ECMO in the ELSO registry.