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2026 SOAP Annual Meeting
April 29 - May 3, 2026 | Montreal, Quebec Canada
2336366
ECMO is in the Birth Plan: Peripartum Management of Severe Pulmonary Hypertension Requiring Preterm Cesarean Delivery
Poster Presenter
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Challenging Acuity
Clinical Problem: Severe Pulmonary Hypertension in Pregnancy
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WHO Class IV → Pregnancy Contraindicated
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Maternal mortality: 12-16% despite modern therapies
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Majority of deaths: postpartum RV failure
Why Pregnancy is Dangerous:
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Physiology: Higher cardiac output, higher plasma volume
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Delivery:
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Autotransfusion: Abrupt preload increase (~500ml)
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Relatively fixed increase in pulmonary vascular resistance
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RV unable to compensate → acute RV failure
Gap in Care:
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No standardized delivery strategy
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High-risk periods(delivery/postpartum)
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Anticipation of hemodynamiccollapse
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Rapid access to advanced support
27F, G5P004, 28w EGA, severe PH (Groups 1, 4 PA 118/39 mmHg), protein S deficiency, PE, BMI 50
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Admitted for medical optimization prior to scheduled CD for breech presentation
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Failed initiation of IV and inhaled epoprostenol, drug-related hypoxic respiratory failure
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Worsening RV failure → Uteroplacental insufficiency → Decreasing amniotic fluid index
1) Delivery Planning:
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Pre-term CD in cardiac OR
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Low Dose CSE
2) ECMO-Standby Strategy:
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Femoral arterial and venous access
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Cardiac surgeon and ECMO available
3) Advanced Monitoring
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Pulmonary artery catheter (PAC)
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Continuous transthoracic echocardiography (TTE)
4) RV-Protective Hemodynamic Management
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Inotropy: dobutamine and epinephrine
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Preload optimization:
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Diuresis (Furosemide IV), therapeutic phlebotomy (800 mL via CVC)
Outcome:
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Hemodynamic stability without ECMO, post-operative diuresis and inhaled NO in CVICU
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Successful maternal recovery
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Neonatal survival
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Discharged with plan for definitive PH therapy
Impact:
1) Utilize a Tier-Based System for ECMO Care
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Planning for worst-case (ECMO) improves safety andtime-to-support in decompensation
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ECMO Aware, ECMO Standby, and ECMO Deployed
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Helps streamline personnel available for delivery,location of delivery, and where patient will recover
2) Physiology-Guided Care is Critical
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PAC + TTE + Awake Patient enable real-time feedbackand RV optimization
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Tailored inotrope/volume management
3) Delivery = Hemodynamic Inflection Point
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Postpartum period carries highest mortality risk
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Requires aggressive, proactive management
4) Novel Strategy: Therapeutic Phlebotomy
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Rapid preload reduction in immediatepostpartum period
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Feasible via existing femoralaccess, hemostatic delivery, and adequatestarting hct
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Potential adjunct for RV offloading