Life saving use of ECMO in an obstetric patient with massive hemorrhage following uterine atony: a case report

The aim of this case report is to present the life saving use of extracorporeal membrane oxygenation (ECMO) in an obstetric pa-tient with acute cardiorespiratory collapse following massive bleeding caused by an atonic uterus post partum. A 39-year-old patient, following a spontaneous abor-tion at 21 weeks of pregnancy, developed uterine atony and massive bleeding and was ultimately referred to the operating room for an emergent hysterectomy. Post-operatively, she was referred to the inten-sive care unit (ICU) where she developed severe acute respiratory distress syndrome (ARDS) that was successfully treated by employing ECMO. Following discontinu-ation of ECMO, her treatment was further complicated by a manifest hemolytic trans-fusion reaction. Although extensive testing was done to establish the cause of this reac-tion, we were unable to find it. The patient responded well to treatment with erythro-poietin (EPO) and corticosteroids as well as a restrictive transfusion regime. This treatment pointed to a possible immune reaction to massive transfusions of blood products. This case demonstrated the im-portance of early aggressive treatment us-ing ECMO in reversal of life threatening ARDS, as well as the need for a judicious approach when transfusing blood prod-ucts.

ECMO (extracorporeal mem-brane oxygenation), hemorrhagic diathesis, obstetric patients

1. Marasco SF, Lukas G, McDonald M, McMillan J, Ihle B. Review of ECMO (extra corporeal membrane oxygenation) support in criti-cally ill adult patients. Heart Lung Circ 2008;17 Suppl 4:S41-7.

2. Nair P, Davies AR, Beca J, Bellomo R, Ellwood D, Forrest P, et al. Extracorporeal membrane oxygenation for severe ARDS in pregnant and postpartum women during the 2009 H1N1 pandemic. Intensive Care Med 2011;37:648-54.

3. Ho CH1, Chen KB, Liu SK, Liu YF, Cheng HC, Wu RS. Early application of extracorporeal membrane oxygenation in a patient with amniotic fluid embolism. Acta Anaesthesiol Taiwan 2009;47:99-102.

4. Lee AJ, Koyyalamudi PL, Martinez-Ruiz R. Severe transfusion-related acute lung injury managed with extracorporeal membrane oxygenation (ECMO) in an obstetric patient. J Clin Anesth 2008;20:549-52.

5. Palanzo DA, Baer LD, El-Banayosy A, Stephenson E, Mulvey S, McCoach RM, et al. Successful treatment of peripartum cardiomyo-pathy with extracorporeal membrane oxygenation. Perfusion 2009;24:75-9.

6. Reyftmann L, Morau E, Dechaud H, Frapier JM, Hedon B. Extracorporeal membrane oxygenation therapy for circulatory arrest due to postpartum hemorrhage. Obstet Gynecol 2006;107(2 Pt 2):511-4.

7. Taiga Itagaki, Mutsuo Onodera, Nao Okuda, Emiko Nakataki, Hideaki Imanaka, Masaji Nishimura. Successful use of extracorporeal membrane oxygenation in the reversal of cardiorespiratory failure induced by atonic uterine bleeding: a case report. J Med Case Rep 2014;8:23.

8. Lamb KM, Cowan SW, Evans N, Pitcher H, Moritz T, Lazar M, et al. Successful management of bleeding complications in patients supported with extracorporeal membrane oxygenation with primary respiratory failure. Perfusion 2013;28:125-31.

9. Maternal Mortality Fact sheet N°348. World Health Organisation [Online] 2014. Available at: http://www.who.int/mediacentre/factsheets/fs348/en/ [2015-04-03]

10. Extracorporeal Life Support Organisation. ELSO Guidelines for Adult Respiratory Failure [Online]. 2013. Available at: https://www. elso.org/Portals/0/IGD/Archive/FileManager/989d4d4d14cusersshyerdocumentselsoguidelinesforadultrespiratoryfailure1.3.pdf [2015-03-04]