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. 2022 Apr 7;26(1):96.
doi: 10.1186/s13054-022-03969-3.

Amniotic fluid embolism rescued by venoarterial extracorporeal membrane oxygenation

Sarah Aissi James  1 , Thomas Klein  2 , Guillaume Lebreton  3   4 , Jacky Nizard  5 , Juliette Chommeloux  1   3 , Nicolas Bréchot  1   3 , Marc Pineton de Chambrun  1   3 , Guillaume Hékimian  1   3 , Charles-Edouard Luyt  1   3 , Bruno Levy  2 , Antoine Kimmoun  2 , Alain Combes  1   3   6 , Matthieu Schmidt  7   8   9   10
Affiliations

Amniotic fluid embolism rescued by venoarterial extracorporeal membrane oxygenation

Sarah Aissi James et al. Crit Care. .

Abstract

Background: Amniotic fluid embolism (AFE) is a rare but often catastrophic complication of pregnancy that leads to cardiopulmonary dysfunction and severe disseminated intravascular coagulopathy (DIC). Although few case reports have reported successful use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) with AFE, concerns can be raised about the increased bleeding risks with that device.

Methods: This study included patients with AFE rescued by VA-ECMO hospitalized in two high ECMO volume centers between August 2008 and February 2021. Clinical characteristics, critical care management, in-intensive care unit (ICU) complications, and hospital outcomes were collected. ICU survivors were assessed for health-related quality of life (HRQL) in May 2021.

Results: During that 13-year study period, VA-ECMO was initiated in 54 parturient women in two high ECMO volume centers. Among that population, 10 patients with AFE [median (range) age 33 (24-40), SAPS II at 69 (56-81)] who fulfilled our diagnosis criteria were treated with VA-ECMO. Pregnancy evolved for 36 (30-41) weeks. Seven patients had a cardiac arrest before ECMO and two were cannulated under cardiopulmonary resuscitation. Pre-ECMO hemodynamic was severely impaired with an inotrope score at 370 (55-1530) μg/kg/min, a severe left ventricular ejection fraction measured at 14 (0-40)%, and lactate at 12 (2-30) mmol/L. 70% of these patients were alive at hospital discharge despite an extreme pre-ECMO severity and massive blood product transfusion. However, HRQL was lower than age-matched controls and still profoundly impaired in the role-physical, bodily pain, and general health components after a median of 44 months follow-up.

Conclusion: In this rare per-delivery complication, our results support the use of VA-ECMO despite intense DIC and ongoing bleeding. Future studies should focus on customized, patient-centered, rehabilitation programs that could lead to improved HRQL in this population.

Keywords: Amniotic fluid embolism; Cardiogenic shock; Disseminated intravascular coagulopathy; Extracorporeal membrane oxygenation; Outcomes.

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Conflict of interest statement

Pr Combes reports grants from Getinge, personal fees from Getinge, Baxter and Xenios outside the submitted work. Pr Schmidt reports receiving personal fees from Getinge, Drager, and Xenios, outside the submitted work. Pr Kimmoun reports receiving personal feels from Aguettant outside the submitted work. No other disclosures were reported.

Figures

Fig. 1
Fig. 1
Study flowchart. AFE amniotic fluid embolism, VA-ECMO venoarterial extracorporeal membrane oxygenation, ICU intensive care unit
Fig. 2
Fig. 2
Comparison of mean SF-36 scores of AFE survivors treated by ECMO after a median follow-up of 40 months after intensive care unit discharge and their age- and sex-matched French control subjects [10], and 84 venovenous ECMO treated ARDS survivors [12], and 32 severe septic shock rescued by VA-ECMO [13]. Higher scores denote a better health-related quality of life. ARDS acute respiratory distress syndrome, VV-ECMO venovenous extracorporeal membrane oxygenation, VA-ECMO venoarterial extracorporeal membrane oxygenation
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