•36F G2P1 at 8 weeks gestation with a past medical history of palpitations and NSVT presented to SBUH after a witnessed cardiac arrest at home.

•CPR in the field led to ROSC upon arrival to the ED where she was placed on VA ECMO for cardiogenic shock and malignant arrythmia.

•The patient underwent cardiac catheterization which showed patent coronaries and Takotsubo cardiomyopathy with an ejection fraction (EF 10%).

•Initial ECMO conditions were complicated by “chatter” and suspected acute blood loss with hemoglobin nadir of 5g/dL.

•After stabilization, the patient was noted to have a distended abdomen with a large amount of intrabdominal fluid demonstrated on POCUS, as well as no intrauterine pregnancy with beta hCG above discriminatory zone, suspicious for ruptured ectopic pregnancy.

•The patient subsequently underwent exploratory laparotomy with evacuation of 3-4L hemoperitoneum and unilateral salpingectomy.

•The patient was transitioned to VV ECMO POD1, and decannulated and extubated POD3 with an EF 70%.

 

Discussion:

ECMO in pregnancy is rare. Acute respiratory distress syndrome is the most common indication, followed by cardiogenic shock and rarely, cardiac arrest [1]. A recent literature search describes 2.2% of cases requiring ECLS in the first trimester of pregnancy, with most patients being placed on VV ECMO [2]. Takutsubo cardiomyopathy occurs under conditions of extreme stress and is characterized by a temporary, often reversable stunning of the myocardium. A potential underlying cardiac condition and stress from acute blood loss and cardiac arrest likely precipitated the stress cardiomyopathy in this patient.

 

The most common complication reported in pregnant patients requiring ECMO was major bleeding requiring large volumes of packed red blood cell transfusion [2]. Intraoperative management of our patient required diligent resuscitation with packed red blood cells, fresh frozen plasma, platelets, and cryoprecipitate. Resuscitation efforts along with resolution of her intrabdominal bleeding likely contributed to the improvement of her clinical status and ability to ultimate extubation and decannulation

 

References: 

1. Naoum EE, Chalupka A, Haft J, MacEachern M, Vandeven CJ, Easter SR, Maile M, Bateman BT, Bauer ME. Extracorporeal life support in pregnancy: a systematic review. Journal of the American Heart Association. 2020 Jul 7;9(13):e016072.

2. Moore SA, Dietl CA, Coleman DM. Extracorporeal life support during pregnancy. J Thorac Cardiovasc Surg. 2016;151:1154–1160.