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Delivery on ECMO

Arthur Jason Vaught: The case illustrates that advanced mechanical support may be a viable option.
Arthur Jason Vaught: The case illustrates that advanced mechanical support may be a viable option.
Arthur Jason Vaught: The case illustrates that advanced mechanical support may be a viable option.

Gynecology & Obstetrics
December 8, 2015

Up to 22 weeks’ gestation, 37-year-old Peggy Chung was having an uneventful pregnancy—until suddenly, she wasn’t.

When Johns Hopkins maternal-fetal medicine specialist Janyne Althausand maternal-fetal medicine fellow Arthur Jason Vaught met Chung, she had been airlifted from another hospital in acute respiratory distress after suspected pneumonia. Additional workup at Johns Hopkins revealed influenza infection and diffuse bleeding in her lungs.

However, even with antiviral treatment and respiratory support, Chung’s fever was unrelenting, her pulmonary bleeding worsened and one of her lungs collapsed. Clinicians then initiated steroid treatment and ordered a CT scan, which revealed multiple bilateral cysts on Chung’s lungs, a sign of  lymphangioleiomyomatosis (LAM), a rare disease with a predilection for women of childbearing age that’s characterized by the abnormal proliferation of smooth-muscle cells in the lungs or other organs.

With conventional techniques to improve Chung’s lung failure and airway bleeding unsuccessful, her care team decided to place her on extracorporeal membrane oxygenation. Using ECMO during pregnancy isn’t unprecedented; Vaught notes a few cases in the literature describing its use for pregnant patients who had influenza and other acute respiratory issues. “There’s good data,” he says, “that pregnancy is not a contraindication.”

However, Vaught adds, there’s little information about delivery on ECMO. But as Chung’s condition continued to worsen, it looked increasingly like that would be her only option, even though her fetus was now only at about 24 weeks’ gestation. Escalating blood pressures along with proteinuria suggested that Chung was becoming preeclamptic.

“No one wants to deliver a baby who’s that preterm,” Vaught says. “But we knew that’s what needed to be done.”

Vaught and his colleagues assembled the ideal team to perform Chung’s cesarean delivery, including perfusionists, cardiothoracic and obstetrics anesthesiologists, neonatologists and cardiothoracic surgeons, in addition to obstetricians. All things considered, Vaught says, the delivery was as uneventful as it could go for a patient on ECMO. Although the baby, whom Chung named Ingrid, had a long journey ahead of her in the neonatal intensive care unit and was only 650 grams, she was strong. And Chung herself improved rapidly, going off ECMO three days after delivery and breathing on her own two days after that.

Today, Vaught says, both Chung and Ingrid continue to do well.

“That’s what we love to see,” he says. “My supreme hope for all our patients is to have a healthy mother and healthy baby at the end. It’s extremely gratifying to have been part of such a huge multidisciplinary effort to get them there.”

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