Obstetric Anesthesiology

E   Narrative Review Article

Extracorporeal Membrane Oxygenation for Pregnant

and Postpartum Patients
Michael J. Wong, MD,* Shobana Bharadwaj, MBBS,* Jessica L. Galey, MD,* Allison S. Lankford, MD,†
Samuel Galvagno, DO, PhD,‡ and Bhavani Shankar Kodali, MD*
See Article, page 264
Extracorporeal membrane oxygenation (ECMO) has seen increasing use for critically ill pregnant and
postpartum patients over the past decade. Growing experience continues to demonstrate the feasi-
bility of ECMO in obstetric patients and attest to its favorable outcomes. However, the interaction of
pregnancy physiology with ECMO life support requires careful planning and adaptation for success.
Additionally, the maintenance of fetal oxygenation and perfusion is essential for safely continuing
pregnancy during ECMO support. This review summarizes the considerations for use of ECMO in
obstetric patients and how to address these concerns. (Anesth Analg 2022;135:277–89)

GLOSSARY
APACHE = Acute Physiology and Chronic Health Evaluation; APRV = airway pressure release venti-
lation; aPTT = activated partial thromboplastin time; ARDS = acute respiratory distress syndrome;
COVID-19 = coronavirus disease 2019; ECMO = extracorporeal membrane oxygenation; ELSO
= Extracorporeal Life Support Organization; FIGO = International Federation of Gynecology and
Obstetrics; Fio2 = fraction of inspired oxygen; Hco3 = bicarbonate; HIT = heparin-induced thrombo-
cytopenia; ICU = intensive care unit; MERS = Middle East respiratory syndrome; PEEP = positive
end-expiratory pressure; Pplat = plateau pressure; Sao2 = arterial oxygen saturation; SAPS-2 =
Simplified Acute Physiology Score; SARS = severe acute respiratory syndrome; SOFA = Sequential
Organ Failure Assessment; VAD = ventricular assist device; VA-ECMO = venoarterial ECMO;
VV-ECMO = venovenous ECMO

E
xtracorporeal membrane oxygenation (ECMO)
was historically seldom used for pregnant and
postpartum patients but there is now growing
interest, as reflected by a burgeoning body of case
reports in the past decade.1 To date, few centers have
substantial experience in ECMO support for this pop-
ulation due, in part, to the infrequent nature of criti-
cal illness among pregnant and peripartum women.2,3
Altered maternal physiology, maintenance of fetal
well-being, and obstetric emergencies are all signifi-
cant challenges for critical care clinicians, and cur-
rent ECMO guidelines do not address considerations
From the *Division of Obstetric Anesthesiology, Department of
Anesthesiology, University of Maryland School of Medicine, Baltimore,
Maryland; †Department of Obstetrics and Gynecology, University of
Maryland School of Medicine and Program in Trauma and Anesthesia
Critical Care, Shock Trauma Center, Baltimore, Maryland; and ‡Department
of Anesthesiology, Multi Trauma Critical Care Unit, Shock Trauma Center,
University of Maryland School of Medicine, Baltimore, Maryland.
Accepted for publication November 17, 2021.
Funding: Support was provided solely from institutional and/or departmen-
tal sources.
The authors declare no conflicts of interest.
Work for this study was performed at the University of Maryland School of
Medicine.
Reprints will not be available from the authors.
Address correspondence to Michael J. Wong, MD, Department of
Anesthesiology, University of Maryland Medical Center, 22 S Greene St,
Room S11C, Baltimore, MD 21201. Address e-mail to mike.wong@dal.ca.
Copyright © 2022 International Anesthesia Research Society
DOI: 10.1213/ANE.0000000000005861
to optimize maternal and fetal outcomes.4,5 In this
review, we present the relevant considerations for
ECMO life support in pregnant and postpartum
patients, as well as the practical adaptations that must
be made to accommodate the physiologic changes of
pregnancy.
ECMO INITIATION
Table 1 summarizes specific cardiopulmonary
considerations for ECMO in pregnant patients.
Multidisciplinary team planning is essential for this
population and involves numerous medical and sur-
gical specialties, as well as other specialist health pro-
fessionals (eg, pregnancy heart team).6,7 Table 2 lists
common medications used during ECMO support,
as well as their fetal effects.8 General principles for
obstetric critical care are described elsewhere.9–12
The indications and contraindications for ECMO
during pregnancy are similar to those for the gen-
eral population (Table 3). The most common indica-
tion for venovenous (VV) ECMO in pregnant and
postpartum patients is acute respiratory distress syn-
drome (ARDS), accounting for up to 49% of reported
cases.1 Among these cases, severe viral pneumonia
(ie, H1N1 influenza) is the dominant etiology, while
other causes of ARDS, such as bacteremia, aspira-
tion, trauma, or hypertensive disorders of pregnancy,
together represent only a small minority of cases.

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 ECMO for Obstetric Patients
Table 1. Comparison of Extracorporeal Membrane Oxygenation in Nonpregnant Versus Pregnant Patients
Considerations Nonpregnant patients
Cardiovascular
Cardiac output 4–8 L/min at baseline
Initial ECMO flow between 3 and 4
L/m2/min
Pulmonary/acid-base
Pao2 Maintain >55 to 60 mm Hg (7.3–8.0
kPa)
Sao2 Maintain >80%
pH Maintain >7.30
Paco2 Maintain between 35 and 45 mm Hg
(4.7 and 6.0 kPa)
Less than 40 mm Hg (5.3 kPa) if
evidence of right heart failure
Hco3 23–30 mmol/L at baseline
Cannulation
— Aortocaval compression
Positioning
— Aortocaval compression
Abbreviations: ECMO, extracorporeal membrane oxygenation; Hco3, bicarbonate; Sao2, oxygen saturation.
Although pregnant patients are susceptible to severe
coronavirus infections (eg, severe acute respiratory
syndrome [SARS], Middle East respiratory syndrome
[MERS], and coronavirus disease 2019 [COVID-19]),13
these infections are poorly represented in the reports
of ECMO for obstetric patients.
Cardiovascular indications for venoarterial (VA)
ECMO tend to be heterogeneous and may be more
likely to present or require treatment in the postpartum
period rather than antenatally.1,14,15 These indications
have typically included preexisting cardiomyopathy,
peripartum cardiomyopathy, pulmonary embolism,
amniotic fluid embolism, and cardiac arrest. While
the majority of pregnant or postpartum patients on
VA-ECMO support survive to discharge, those who
require ECMO for pulmonary embolism or cardiac
arrest may have superior survival compared to those
with cardiomyopathy, which may be less reversible.14,15
Maternal inhospital survival for pregnant and peri-
partum patients requiring ECMO has greatly improved,
from 46% 2 decades ago up to 75% presently.1,15,16 In the
Extracorporeal Life Support Organization (ELSO) reg-
istry, survival rates for obstetric patients now exceed
those of the general adult population.15,17 ECMO may
be particularly beneficial for pregnant patients in the
setting of acute cardiac arrest, improving survival to
88% compared to a 59% population-based cardiac
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Pregnant patients
Increased to 6–10 L/min at baseline, due to higher stroke volume and heart rate
Initial ECMO flow between 5 and 6 L/m2/min
May require beta-blockade to reduce metabolic demand and reduce circulation of
deoxygenated blood
Maintain >70 mm Hg (9.3 kPa)
Maintain >90%
Required for fetal oxygenation
Maintain >7.40
Maternal acidosis poorly tolerated by fetus
May consider sodium bicarbonate infusion as a temporizing measure
Ideally maintain between 28 and 32 mm Hg (3.7 and 4.3 kPa)
Maternal hypercapnia and hypocapnia associated with fetal hypoxemia
and acidosis
18–21 mmol/L at baseline, due to compensation for chronic respiratory alkalosis
Left uterine displacement may improve ease of guidewire advancement
Maintain physiologic uteroplacental perfusion
Fetal heart rate monitoring during cannulation may provide early indication of
impaired uterine blood flow during cannulation
Frequent use of ultrasonography to confirm cannula placement
Left uterine displacement while supine
Proning requires careful padding around gravid abdomen
“A” frame configuration depicted in Figure 2
arrest survival rate.1 Fetal survival is similarly favor-
able, around 70% to 75%.1,16 Pregnant patients with
ECMO initiation within 5 days of admission may have
improved survival compared to delayed cannulation.18
Thus, we encourage early referral to a specialized cen-
ter for consideration of ECMO.
Cannulation is similar as for nonpregnant patients
(Figure 1). However, aortocaval compression by
the gravid uterus may impede femoral guidewire
advancement; therefore, it is helpful to have a cushion
under the right hip to provide left uterine displace-
ment during this process.19 After experience with a
variety of cannula configurations during pregnancy,18
our current practice in VV-ECMO is to use a single-
stage 25-Fr drainage cannula in the right femoral vein
and a 23-Fr return cannula in the right internal jugu-
lar vein, which is well tolerated and ensures adequate
flow rates. As in nonpregnant patients, femoral artery
cannulation for VA-ECMO risks critical limb isch-
emia,20 so distal perfusion cannula placement during
primary cannulation is often performed to prevent
this complication.21
DELIVERY PLANNING
Both vaginal and cesarean deliveries have been
reported in pregnant patients on ECMO support.1,22
Decisions around fetal monitoring and obstetric
ANESTHESIA & ANALGESIA
 E  Narrative Review Article

Table 2. Common Medications During ECMO

Fetal/maternal ratio and placental Dosing considerations during ECMO
Medication class transfer Fetal and neonatal considerations support8
Sedatives and Rapid placental transfer Decrease in fetal heart rate
analgesics variability
Propofol 0.54–0.85 No evidence of teratogenicity Many sedative and analgesic medications
Highly protein bound Possible neonatal sedation may require increased dosing, due to
Midazolam 0.3–0.6 Reported fetal effects inconsistent sequestration in the ECMO circuit.
More polar than other Neonatal hypotonia, decreased Lipophilic and protein-bound medications
benzodiazepines sucking reflex and sedation are most affected by sequestration
Dexmedetomidine 0.12 No evidence of teratogenicity (ie, propofol, midazolam,
High placental extraction dexmedetomidine, ketamine, fentanyl,
and remifentanil).
Ketamine 0.76–1.0 Inadequate data Notably, morphine and hydromorphone
Increased uterine activity are more hydrophilic and are thought to
Fentanyl 0.37–1.0 Fetal analgesia have less sequestration.
Moderate placental extraction Neonatal respiratory depression There are limited pharmacokinetic data
Remifentanil 0.5–0.88 Minimal fetal exposure for sedative and analgesic medications
Rapid metabolism Minimal neonatal depression during ECMO support.
Anticoagulants No placental transfer No teratogenicity
Heparin Large molecule No mutagenicity or teratogenicity Heparin may require increased dosages
Does not cross placenta due to lipophilicity and sequestration in
Enoxaparin Large molecule No mutagenicity or teratogenicity the ECMO circuit.
Does not cross placenta There are limited data for the effects
Fondaparinux Does not cross placenta No adequate data of ECMO on pharmacokinetics of
No evidence of animal teratogenicity alternative anticoagulants.
Bivalirudin Does not cross placenta No adequate data Systemic anticoagulation dosing continues
No evidence of animal teratogenicity to be informed by serial laboratory
Argatroban No adequate data No adequate data testing (Table 3).
No evidence of animal teratogenicity
Neuromuscular Ionized with limited transfer Prolonged infusion may affect
blocking agents biophysical profile
Rocuronium 0.16 No evidence of teratogenicity No adequate data
Ionization limits transfer Possible neonatal hypotonia
Cisatracurium 0.07 (0.14 for metabolite Inadequate data No adequate data
laudanosine)
Ionized, very limited transfer Possible neonatal hypotonia
Hoffman elimination
Cardiovascular Cross placenta Maternal benefits should outweigh
fetal and neonatal risks
Amiodarone 0.10–0.28 Inadequate data No adequate data
Metabolite and iodine cross placenta Fetal/neonatal thyroid dysfunction
Digoxin Freely crosses placenta No mutagenicity or teratogenicity No adequate data
Esmolol 0.2 No mutagenicity or teratogenicity; No adequate data
Crosses placenta but quickly Possible fetal bradycardia and
metabolized neonatal hypoglycemia
Milrinone Placental transfer unknown No evidence of teratogenicity No adequate data
Abbreviation: ECMO, extracorporeal membrane oxygenation.

interventions are individualized with consideration
of gestational age, fetal lung maturity, likelihood
of maternal cardiopulmonary recovery, anticipated
ECMO duration, as well as fetal and maternal
comorbidities. Antenatal corticosteroids for fetal
lung maturity are given between viability and 34
weeks.18,23 At our institution, we typically commence
around-the-clock, continuous external fetal moni-
toring as early as 24 weeks for critically ill patients,
with a dedicated labor nurse at the patient’s bedside
for fetal heart rate interpretation and appropriate
intervention. Maternal sedative-hypnotic medica-
tions predictably reduce fetal heart rate variability.
In the event of acutely nonreassuring fetal heart rate
tracing (eg, bradycardia or recurrent decelerations),
reversible causes such as maternal hypoxemia,
hypotension, aortocaval compression, inadequate
ECMO settings, circuit thrombosis, or cannula
malposition must be quickly identified and cor-
rected. Persistently abnormal tracings or maternal
cardiopulmonary instability often warrant urgent
delivery, so in-house high-risk obstetrics cover-
age is required, and instruments for delivery must
be immediately available in the intensive care unit
(ICU). Other methods of fetal assessment, including
serial biophysical profiles and ultrasound growth
assessments, are also performed to identify fetal
compromise necessitating delivery.
In the absence of obstetric indications, elective pre-
term delivery during critical illness is controversial. If

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 ECMO for Obstetric Patients

Table 3. Indications and Contraindications for Initiating Extracorporeal Membrane Oxygenation

VV-ECMO indications
General population During pregnancy
Hypoxic respiratory failure when predicted risk of mortality is ≥50% Hypoxic respiratory failure
as determined by validated risk score (eg, SOFA, SAPS-2, and Pao2/Fio2 ratio <80 for >6 h
APACHE) Pao2/Fio2 ratio <50 for >3 h
Hypercapnia (Paco2 > 60 mm Hg or 8.0 kPa) and/or pH < 7.25 on Hypercarbia (Paco2 > 50 mm Hg or 6.7 kPa) and/or pH < 7.25 on
mechanical ventilation despite high Pplat mechanical ventilation despite high Pplat (> 30 cm H2O)a
(>30 cm H2O)a Physician clinical discretion
Physician clinical discretion

VV-ECMO contraindications
>10 days mechanically ventilatedb
Requirement for home O2 therapy for severe lung disease
Inability to tolerate anticoagulation
Severe acute or chronic liver disease
Ongoing/uncontrolled hemorrhage
Unwilling to receive blood products
Major immunosuppression (absolute neutrophil count <400/mm3; lymphocyte count <1000/microliter)
Central nervous system hemorrhage that is recent or expanding
Nonrecoverable comorbidity such as major neurologic damage or terminal malignancy
No specific age contraindication but increasing risk with increasing age; usual age cutoff varies by institution, usually 65 or 70 y

VA-ECMO indications
General population During pregnancy
Inadequate tissue perfusion (hypotension and low cardiac output) Inadequate tissue perfusion (hypotension and low cardiac output) despite
despite adequate intravascular volume, inotropic support, and adequate intravascular volume, inotropic support, and vasoconstrictors
vasoconstrictors Fetal status allows sufficient time for cannulation and ECMO initiation
Septic shock is an indication in some centers VA-ECMO must be considered early given risk of cardiogenic shock to
Physician clinical discretion fetal well-being
Physician clinical discretion
VA-ECMO contraindications
Unrecoverable cardiac function and not a candidate for VAD or transplant
Inability to tolerate anticoagulation
Ongoing/uncontrolled hemorrhage
Unwilling to receive blood products
Major immunosuppression
Central nervous system hemorrhage that is recent or expanding
Nonrecoverable comorbidity such as major neurologic damage or terminal malignancy
Chronic organ dysfunction (emphysema, cirrhosis, and renal failure)
Prolonged cardiopulmonary resuscitation without tissue perfusion
No specific age contraindication but increasing risk with increasing age; usual age cutoff varies by institution, usually 65 or 70 y
Abbreviations: APACHE, Acute Physiology and Chronic Health Evaluation; ECMO, extracorporeal membrane oxygenation; Fio2, fraction of inspired oxygen; Pplat,
plateau pressure; SAPS-2, Simplified Acute Physiology Score; SOFA, Sequential Organ Failure Assessment; VA, venoarterial; VAD, ventricular assist device; VV,
venovenous.
a
Despite optimization of mechanical ventilation and despite attempts at rescue maneuvers (eg, inhaled nitric oxide, inhaled epoprostenol, prone positioning,
and neuromuscular blockade).
b
Many institutions specify mechanical ventilation duration that must be <7 days.

there is ongoing maternal cardiopulmonary dysfunc-
tion, it may be desirable to plan for elective vaginal
or, more likely, cesarean delivery under controlled
conditions to mitigate the potential for later emer-
gent delivery due to fetal heart rate abnormalities.
Yet, prematurity is associated with neonatal morbid-
ity and mortality, and early delivery does not guar-
antee improved maternal outcomes.24–26 Additionally,
cesarean delivery is a major surgery with consider-
able maternal inflammatory burden and risks of hem-
orrhage, hemodynamic instability, or infection. Prior
reports have also demonstrated the feasibility of preg-
nancy maintenance for several weeks during ECMO
support.1,18,27 Balancing the risks to mother and fetus,
it is reasonable to aim for a goal of 28 to 32 weeks
gestation for delivery timing.28,29 Ultimately, it is the
team’s decision to consider all relevant factors before
undertaking cesarean delivery while on ECMO.
VENTILATION AND OXYGENATION
Oxygen consumption increases by 20% during preg-
nancy30 and ECMO flows must be adjusted accord-
ingly. While an arterial oxygen saturation (Sao2) >80%
represents adequate oxygenation during ECMO sup-
port in nonpregnant adult patients,27 such a degree
of relative hypoxemia is unacceptable during preg-
nancy. Assuming normal uteroplacental blood flow is
maintained, a minimum maternal Pao2 of 60 mm Hg
(8.0 kPa) is required to ensure adequate fetal oxygen-
ation, as reflected by maternal Sao2 >90%.30 In prac-
tice, ECMO flows are titrated to achieve a maternal
Sao2 >95%.18 Recurrent fetal decelerations or other

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 E  Narrative Review Article

Figure 1. Commonly used cannulation configurations for VV- and VA-ECMO. A, Internal jugular-femoral configuration for VV-ECMO. Blood is
taken (outflow/drainage cannula) from the femoral vein and returned (inflow/return cannula) to the right internal jugular vein after passing
through the oxygenator. B, Femoral-femoral configuration for VA ECMO. A cannula is placed in the femoral artery to provide retrograde blood
flow to the heart. A drainage cannula is placed in the contralateral femoral vein. ECMO indicates extracorporeal membrane oxygenation; VA,
venoarterial; VV, venovenous.

Figure 2. Cushioning for prone

positioning during pregnancy. A,
Aerial view of the patient, rest-
ing on an “A” frame configura-
tion of cushions. The pelvis and
upper body are supported by 2
limbs of the “A,” and the pelvis
is supported by a horizontal
cushion. The abdomen is free in
the hollow of the “A” frame, and
there is space to insert a fetal
heart rate monitor and a toco-
dynamometer. B, Lateral view
of patient on the “A” frame. The
head is turned to 1 side, with
ipsilateral arm in swimmers’
position. Cushions support the
lower extremities to facilitate
cannula flow by avoiding exces-
sive hip flexion.

fetal heart rate tracing abnormalities may indicate the
need to augment maternal oxygenation via increased
ECMO flow or other methods such as prone posi-
tioning.27 As such, continuous fetal heart rate tracing
serves as a “fifth vital sign” for maternal well-being,
since it can herald physiologic derangement before
maternal decompensation.31
Cardiac output increases 30% to 50% by the third
trimester, which may reduce the efficiency of oxygen-
ation during ECMO.10 Higher cardiac output results in
more venous blood bypassing the drainage cannula
and proceeding to the heart without being oxygen-
ated.32 In adult patients, ECMO flows typically begin
around 60 to 80 mL/kg/min (3–4 L/m2/min); how-
ever, during pregnancy, ECMO flows of 100 to 120
mL/kg/min (5–6 L/m2/min) are often necessary to
compensate for elevated cardiac output and improve
oxygenation.4 Further increasing ECMO flow eventu-
ally predisposes to undesirable recirculation between
drainage and return cannulas, as well as chatter,
hemolysis, and thrombocytopenia.32,33 Beta-adrenergic
antagonists can help reduce excessive cardiac output

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 ECMO for Obstetric Patients
while on ECMO34, and this approach is acceptable for
pregnant patients.33 Esmolol or metoprolol is used to
target a maternal heart rate of 100 beats per minute or
lower. Additional venous drainage cannula placement
may also be considered when flow is limited by can-
nula size such that oxygenation goals cannot be met.35
At our institution, we have not required extra drain-
age cannulas for pregnant patients on ECMO support,
but for nonpregnant patients, this would usually entail
insertion of a 21- to 23-Fr single lumen cannula, with
the most common location for additional drainage can-
nula placement being the left femoral vein.
During normal pregnancy, increased minute ven-
tilation reduces Paco2 to a range of 28 to 32 mm Hg
(3.7–4.3 kPa), creating a favorable partial pressure
gradient for fetal carbon dioxide elimination and oxy-
gen uptake.36,37 Since the fetus has limited capability to
buffer for major acid-base disturbances,38,39 it is ideal to
maintain this physiologic Paco2 range though it may
be difficult to accomplish initially. Fetal acidosis shifts
the oxygen-hemoglobin dissociation curve rightward,
reducing fetal oxygen-carrying capacity and contrib-
uting to a vicious cycle of worsening hypoxemia and
acidosis. Although brief periods of hypercapnia up to
60 mm Hg (8.0 kPa) are tolerated by fetuses of healthy
volunteers, a safe threshold for permissive hypercap-
nia in the context of ongoing maternal critical illness
remains undetermined.40,41 Therefore, hypercapnia
(Paco2 > 40 to 45 mm Hg, or 5.3–6.0 kPa) should be
avoided, and a target Paco2 in the range of 28 to 32
mm Hg (3.7–4.3 kPa) should be gradually pursued as
it becomes increasingly feasible.11,12,27,42 Additionally,
hypocapnia (Paco2 < 15 to 25 mm Hg, or 2.0–2.7 kPa)
must also be avoided, as it causes fetal acidosis via
uterine artery vasoconstriction.38,43,44
Where pregnancy is a state of chronic, partially
compensated metabolic alkalosis,37 maternal acidosis
(pH < 7.25) is generally poorly tolerated by the fetus.
In our experience, progressive maternal acidosis por-
tends the development of a nonreassuring fetal heart
rate tracing unless corrective measures are taken, and
low maternal pH may be more deleterious than mater-
nal hypercarbia. Thus, while its underlying causes are
identified and addressed, our practice is to temporize
maternal acidosis by raising maternal pH closer to 7.4
with an infusion of sodium bicarbonate (150 mEq of
sodium bicarbonate in 1 L of 5% dextrose in water). In
severe refractory maternal acidosis, continuous renal
replacement therapy may be considered concurrent to
ECMO support (eg, continuous VV hemofiltration)45;
however, this must not delay preparation for possible
emergent cesarean delivery.
Of note, fetal and maternal acid-base status change
in tandem, with fetal pH trending approximately 0.1
lower than maternal pH.46 With normal uteroplacen-
tal blood flow, fetal and maternal Paco2 are similarly
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correlated, where fetal Paco2 is about 10 mm Hg (1.3
kPa) greater than maternal Paco2.47 These relation-
ships can guide the indirect assessment of fetal well-
being, in addition to fetal heart rate monitoring.
Minute ventilation increases 30% to 50% in preg-
nancy, largely driven by a 40% increase in spontaneous
tidal volume.30 Because of this, lung-protective venti-
lation results in relative hypoventilation for pregnant
patients, which may contribute to fetal acidosis as well
as loss of fetal physiologic reserve. Increasing the respi-
ratory rate during mechanical ventilation may not ade-
quately address this relative maternal hypoventilation,
so it may be necessary to accept somewhat higher tidal
volumes and airway pressures (up to 35 cm H2O). It is
noteworthy that pregnant patients were excluded from
seminal investigations demonstrating the superiority of
lung-protective ventilation in ARDS.48 The use of trans-
pulmonary pressure monitoring has been suggested in
other populations to optimize ventilation parameters49;
however, this approach has not been studied in preg-
nant patients. Considering increased intra-abdominal
pressure and decreased chest wall compliance observed
during pregnancy, it is unclear at what threshold slightly
higher tidal volumes may meaningfully affect transpul-
monary pressures.40,50 Notwithstanding, VV-ECMO
facilitates minimization of ventilator support during
maternal respiratory failure.
For pregnant and nonpregnant patients alike, opti-
mal ventilation parameters during ECMO have yet
to be determined.51 At our institution, “lung rest”
on VV-ECMO is generally achieved using pressure
control ventilation with a peak inspiratory pressure
set at 20 to 25 cm H2O, positive end-expiratory pres-
sure (PEEP) of 10 to 15 cm H2O, respiratory rate of
10 breaths per minute, and fraction of inspired oxy-
gen (Fio2) at 30% to 40%.52–54 This tends to be ade-
quate for pregnant and nonpregnant patients alike,
as oxygenation and carbon dioxide elimination are
accomplished via the ECMO membrane lung. There
is increasing awareness that elevated driving pres-
sure (ie, tidal volume normalized to lower respiratory
system compliance or plateau pressure [Pplat] minus
PEEP) is associated with increased mortality during
ARDS.55,56 Thus, it is also desirable to periodically
monitor driving pressure and keep it <15 to 20 cm
H2O. Tidal volumes and compliance on lung rest set-
tings are trended over the course of days to weeks and
help demonstrate whether lung recovery is occurring.
In some instances of refractory hypoxemia, we use
airway pressure release ventilation (APRV) with pres-
sure during inspiration (P-high) maintained <30 cm
H2O to reduce the risk of barotrauma.57
PRONE POSITIONING
Prone positioning is an effective intervention for
improving oxygenation and survival in ARDS.58
ANESTHESIA & ANALGESIA
 E  Narrative Review Article
Although logistically challenging, it may be safely
performed during ECMO support59–61 and through-
out pregnancy.18,62 We use prone positioning for preg-
nant patients with moderate to severe ARDS (Pao2/
Fio2 ratio <150 to 200) despite optimizing ventilation,
including patients on ECMO. The exclusion criteria
for prone positioning are similar as for nonpregnant
patients, though the process may be more onerous
in the third trimester.29 Additionally, in the presence
of an acutely nonreassuring fetal heart rate tracing,
prone positioning may be inadvisable. Alternatively,
for pregnant patients on ECMO who may benefit
from prone positioning but have contraindications or
in settings with resource and personnel constraints
that render proning impractical, other authors have
suggested lateral decubitus positioning.16,63
An experienced team is required for successful
prone positioning during pregnancy, especially dur-
ing ECMO support. For these patients, at least 4 team
members are required when prone positioning or
repositioning to supine (ie, perfusionist, respiratory
therapist, ICU nurse, and obstetric nurse). A mechani-
cal lift greatly improves safety and convenience.
Relevant consultants are also notified before position-
ing in the event of maternal decompensation or non-
reassuring fetal status (ie, obstetrics or maternal-fetal
medicine, obstetric anesthesiology, and neonatology).
Figure 2 demonstrates our approach to prone posi-
tioning for ventilated and sedated pregnant patients,
which involves an “A” frame configuration for patient
cushioning. We have had success using several differ-
ent materials for constructing an “A” frame, includ-
ing rolled blankets or proprietary padding products
such as Convoluted Pad (Span-America Medical
Systems) or Z Flo Fluidized Positioner (Molnlycke
Health Care). The upper and lateral parts of the body
are supported by the 2 limbs of the “A,” and the hori-
zontal bar of “A” supports the pelvis below the ante-
rior superior iliac spines. The size of the triangle in
the “A-frame” is adjusted to provide enough space
for the abdomen to rest without touching the bed, to
avoid compression of the aorta and inferior vena cava
by the gravid uterus. The fetal heart rate monitor is
placed between the bed and the abdomen. Whenever
feasible and required, a tocodynamometer is used
with an elastic belt. Both lower limbs are supported
adequately to limit hip flexion and so facilitate blood
flow via femoral cannulas. The head is turned to 1
side and the arm on the same side is placed in swim-
mer’s position. The fetal heart rate monitor and the
tocodynamometer are disconnected from the moni-
toring base station when patients are moved between
prone and supine positions.
In our institutional proning protocol, patients are
placed for a goal of 16 hours in prone position and repo-
sitioned supine for 8 hours though, in practice, it may be
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necessary to return to supine position sooner if the fetus
is challenging to continuously monitor while prone.
Other concerns that may prompt early return to supine
positioning include frequent uterine contractions, new
or worsening nonreassuring fetal heart tracing, and
deteriorating maternal hypoxemia or hemodynamics.
Daily prone positioning sessions are planned until there
ceases to be improvement in maternal blood gas mea-
surements, chest radiography, or lung compliance, or if
there is evidence of pressure injury.
UTEROPLACENTAL PERFUSION
At term, uterine oxygen consumption is approxi-
mately 25 mL/min, primarily due to fetal and pla-
cental demands.64 Fetal oxygenation is maintained
by numerous physiologic adaptations, including left-
ward shift of the fetal oxygen-hemoglobin dissociation
curve, high fetal cardiac output, fetal polycythemia,
and distribution of fetal blood flow to vital organs.65,66
However, fetal oxygen delivery may be precarious
in the critically ill pregnant patient due to upstream
effects of maternal hypoxemia, hypovolemia, anemia,
and acidosis on uterine perfusion. Uterine blood flow
is poorly autoregulated and depends on maintaining a
uterine perfusion pressure greater than uterine vascu-
lar resistance.67 Aortocaval compression by the gravid
uterus may impair maternal venous return, cardiac out-
put, and subsequent uteroplacental perfusion. Hence,
after 20 weeks gestation, patients should be positioned
in left lateral decubitus position or have a cushion
under their right hip while they are supine.12,42,68,69
Prone positioning should result in complete resolu-
tion of aortocaval compression, provided the patient is
adequately padded to offload the gravid uterus. Other
factors impairing uteroplacental blood flow include
systemic hypotension, hypovolemia, hypothermia,
as well as circulating catecholamines and exogenous
vasoconstrictors. Femoral vein cannulation itself may
theoretically increase venous backpressure within the
uterine vasculature and reduce uteroplacental perfu-
sion.70 Because of this, continuous fetal monitoring
during cannulation can provide real-time feedback on
disruption of uteroplacental blood flow by the cannula
and indicate a need to withdraw it slightly.
The specific impact of VA-ECMO on uterine cir-
culation is unknown, though animal models of car-
diopulmonary bypass demonstrate less effective
uteroplacental perfusion with nonpulsatile flow com-
pared to pulsatile flow.71 Accordingly, continuous fetal
monitoring is particularly desirable during VA-ECMO,
where the nonpulsatile nature of the ECMO pump may
provide somewhat reduced uteroplacental perfusion
compared to the native heart. If the fetal heart rate trac-
ing becomes nonreassuring, augmentation of mater-
nal blood pressure or increased ECMO flow may help
avoid an emergent delivery. Limited case reports have
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 ECMO for Obstetric Patients

also suggested the use of an intraaortic balloon pump
can mimic physiologic, pulsatile blood flow and poten-
tially improve fetal well-being during cardiopulmonary
bypass.72
BLOOD MANAGEMENT
Severe anemia is proactively investigated and treated
during ECMO support, since the oxygen-carrying
capacity of blood depends on hemoglobin concen-
tration.73 Although ELSO guidelines recommend
maintaining hematocrit over 40% during ECMO (or,
hemoglobin greater than approximately 13 g/dL),74
a recent systematic review showed no advantage of
liberal transfusion strategies over restrictive transfu-
sion thresholds for patients on VV- or VA-ECMO (ie,
hemoglobin goal exceeding 7–10 g/dL).75 At our insti-
tution, hemoglobin <7 g/dL is the typical transfusion
threshold for both pregnant and nonpregnant patients
on ECMO support. If there is concern for inadequate
tissue oxygenation despite attaining a target maternal
Sao2 of 95%, cardiac output may be calculated using
transthoracic or transesophageal echocardiography to
determine whether a higher hemoglobin threshold is
required to maintain desired oxygen delivery.
Thrombocytopenia is common during ECMO
due to platelet activation by circuit components, sys-
temic inflammation, medications, and underlying
comorbidity.73,76,77 Although infrequent, spontane-
ous intracranial hemorrhage during ECMO support
can be a devastating complication relating to severe
thrombocytopenia. ELSO guidelines recommend plate-
let transfusion to maintain a count >80,000 × 109/L74;
however, lacking robust evidence for this recommen-
dation, other authors suggest lower platelet transfusion
thresholds around 40,000 to 50,000 × 109/L.73,78 In our
practice, we typically maintain a platelet count >40,000
× 109/L to balance competing risks of thrombotic and
hemorrhagic complications. Notably, hemostasis may
yet be abnormal despite a numerically adequate plate-
let count, since exposure to circuit components causes
qualitative platelet dysfunction in virtually all ECMO
patients (ie, acquired von Willebrand disorder).73,79
ANTICOAGULATION
Although pregnancy is a hypercoagulable state, char-
acterized by increases in factors VII, VIII, X, XII, tissue
factor, von Willebrand factor, and fibrinogen,80 there is
little evidence that pregnancy increases susceptibility to
oxygenator or ECMO circuit thrombosis.35 Nonetheless,
vigilance for clot formation within the ECMO circuit
is advisable for all patients. Unfractionated heparin is
the systemic anticoagulant of choice for ECMO during
pregnancy, since it is widely available, inexpensive,
reversible, does not cross the placenta, and is not asso-
ciated with congenital malformations.73,74,81–83 As in the
general population, optimal anticoagulation monitor-
ing for obstetric patients on ECMO has not yet been
determined.84 Table 4 summarizes laboratory and
point-of-care tests for monitoring heparin effect during
ECMO. At our institution, heparin is given as a bolus

Table 4. Laboratory Tests to Guide Anticoagulation Management During Extracorporeal Life Support
Assay Target range Considerations
aPTT 45–80 s Plasma-based test
Widely available
Slow turnaround time
Influenced by fibrinogen concentration, clotting factor concentrations, bilirubin concentration, plasma free
hemoglobin concentration, antiphospholipid antibody, liver disease, and hemodilution
Not influenced by thrombocytopenia
Variable results between different laboratory reagents
ACT 160–220 s Whole blood test
Inexpensive
Rapid turnaround time
Widely used in cardiac surgery
Imperfectly correlates with UFH effect at doses commonly used for ECMO
Also influenced by oral anticoagulation, thrombocytopenia, platelet dysfunction, hemodilution,
hypofibrinogenemia, antithrombin concentration, and hypothermia
Variable results between different devices
Anti-Xa 0.3–0.7 U/mL Most closely reflects UFH effect
Slow turnaround time
Also influenced by bilirubin concentration, plasma free hemoglobin concentration, and triglyceride concentration
Not influenced by factor deficiencies, thrombocytopenia, hemodilution, and oral anticoagulants
Not widely available
Variable results between different laboratory protocols
TEG/ROTEM — Whole blood test
Reflects multiple phases of coagulation in real time
Expertise required for interpretation
Also influenced by plasma free hemoglobin concentration and specific reagents used
Abbreviations: ACT, activated clotting time; aPTT, activated partial thromboplastin time; ECMO, extracorporeal membrane oxygenation; ROTEM, rotational
thromboelastometry; TEG, thromboelastography; UFH, unfractionated heparin.

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 E  Narrative Review Article
during cannulation (50–100 units/kg) and then as a
continuous infusion titrated according to laboratory
testing and clinical evaluation. For VA-ECMO, our acti-
vated partial thromboplastin time (aPTT) goal is 60 to
80 seconds. During VV-ECMO, our aPTT goal is typi-
cally 45 to 55 seconds for both pregnant and nonpreg-
nant patients, though a higher goal of 60 to 80 seconds
is used in the presence of COVID-19.
Although the threat of circuit thrombosis usually
necessitates systemic anticoagulation during general
usage, heparin-bonded circuit tubing reduces this
risk.79 There is increasing experience with maintain-
ing ECMO support while withholding systemic anti-
coagulation, in situations such as hemorrhage. In
addition to heparin-bonded circuit tubing, polymeth-
ylpentene oxygenators and centrifugal pumps have
also promised to reduce the risk of circuit thrombo-
sis. Recent case series in nonpregnant patients indi-
cate that circuit thrombosis risk is not increased in
VV-ECMO without systemic anticoagulation, and the
practice may decrease bleeding events and transfu-
sion requirements.85,86 Depending on the duration of
ECMO support without systemic anticoagulation,
multiple changes of oxygenators or circuit compo-
nents may be reasonably expected. It is essential to
maintain ongoing vigilance for visible circuit throm-
bosis or flow drops that may promote clotting, and
the team must always be prepared to urgently change
circuit components if necessary. Serial markers of
hemolysis such as lactate dehydrogenase and plasma
free hemoglobin further inform ongoing decisions
about anticoagulation resumption. At our institution,
we have had favorable outcomes in patients contin-
ued on prolonged VV-ECMO runs without systemic
anticoagulation. Although our experience and com-
fort with this practice have improved during recent
years, we still consider it preferable to maintain sys-
tematic anticoagulation during ECMO support, par-
ticularly for VA-ECMO that has a 9% incidence of
circuit-related clot, which may be catastrophic.87–89
When there are indications for fetal delivery, the
decision to reverse or hold systemic anticoagulation
before delivery must be individualized, as data to
inform best practices are few. At our institution, sys-
temic heparin is stopped for at least 2 hours before a
scheduled cesarean delivery on ECMO, and we con-
sider restarting it after 24 to 48 hours if hemostasis
is adequate. With heparin-bonded components, we
have not had frequent thrombotic complications from
pausing systemic anticoagulation periprocedurally.
Heparin-induced thrombocytopenia (HIT) dur-
ing ECMO is an uncommon complication associated
with significant thrombotic morbidity and mortality.
The risk of HIT in pregnant women on ECMO sup-
port has not specifically been evaluated. However,
pregnancy itself is potentially protective against
August 2022 • Volume 135 • Number 2
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HIT, as demonstrated by the relatively lower inci-
dence of HIT among hospitalized pregnant women
(below 0.1%) compared to nonpregnant hospital-
ized patients.90 Due to the elevated risk of systemic
thrombosis in patients with HIT, heparin infusions
should be discontinued and alternative anticoagula-
tion agents administered.91 Argatroban, danaparoid,
fondaparinux, and bivalirudin have been used for
alternative systemic anticoagulation during ECMO in
patients with HIT,91 and they are also appropriate for
pregnant patients.92,93 If heparin-bonded circuit tub-
ing is used, the heparin coating can potentially con-
tribute to HIT and platelet consumption; therefore, it
is preferable to promptly change these components
when patient stability permits.
On discontinuation of VV-ECMO, 85% of patients
demonstrate cannula site thrombosis, which is inde-
pendent of their ECMO run time or anticoagulation
regimen.94 During VA-ECMO support, there is a 14%
rate of arterial complications, including thrombosis
and vessel stenosis, and up to 7% of patients develop
critical limb ischemia requiring urgent thrombec-
tomy.95 While it is unclear whether pregnant patients
are more susceptible to thromboembolic complica-
tions, given the thrombophilic tendency in preg-
nancy, it is prudent to perform duplex ultrasound
of cannula sites after decannulation. Patients with
evidence of cannula site thrombosis should receive
therapeutic anticoagulation until sonographic resolu-
tion. Additionally, massive pulmonary embolism or
severe maternal cardiomyopathy is a relatively com-
mon indication for VA-ECMO initiation in pregnant
patients, and these conditions would also necessitate
prolonged anticoagulation after decannulation.
Hemorrhagic complications are seen in 37% of
obstetric patients on ECMO,15 and this is comparable
to the general population.73 Bleeding may occur from
numerous potential sources, including the pulmo-
nary vasculature, thorax, cranium, gastrointestinal
tract, cannulation sites, or tracheostomy.68 If bleeding
occurs after fetal delivery, obstetric causes of bleed-
ing must also be considered, such as uterine atony,
retained placenta, and traumatic delivery. For uncon-
trolled hemorrhage, temporary suspension of sys-
temic anticoagulation may be balanced against the
risk of circuit thrombosis. Viscoelastic tests help to
target treatment of specific coagulopathies.73
DISCONTINUATION OF ECMO SUPPORT
Scant data exist to guide strategies for weaning ECMO,
so practice is highly variable.96–98 As in nonpregnant
patients, weaning commences alongside clinical evi-
dence of native organ recovery, and ECMO settings (ie,
sweep gas flow, sweep Fio2, and ECMO flow) are pro-
gressively reduced until a trial off ECMO is attempted.
The presence of new or worsened abnormalities in the
www.anesthesia-analgesia.org 285
 ECMO for Obstetric Patients
fetal heart rate tracing on reducing ECMO parameters
provides additional feedback to direct the weaning pro-
cess, potentially indicating a need to restore previous
settings.
Decannulation typically takes place at the bedside
for VV-ECMO after the patient is demonstrated to tol-
erate a minimal sweep gas flow (ie, 0–1 L/min) while
on acceptable ventilator settings. For VA-ECMO,
decannulation is performed in the operating room
pending echocardiographic assessment of valvular
and biventricular function; during weaning, ECMO
flow is decreased by 500 mL every 5 to 10 minutes
until reaching a minimum flow of 1 L/min. Barring
cardiac decompensation after another 5 minutes,
decannulation may occur, often with the aid of a per-
cutaneous closure device.
ETHICAL CONSIDERATIONS
Critical care during pregnancy can be ethically com-
plex and further complicated by ECMO support.99–101
ECMO initiation is usually uncontroversial as a
maternal bridge-to-survival or bridge-to-transplant
during cardiopulmonary failure, and ECMO support
helps continue the pregnancy in an effort to reduce
fetal morbidity from prematurity.27 However, later
choices concerning withdrawal of care or prolonged
maintenance of life support can be contentious, par-
ticularly when patient’s wishes are unknown or when
maternal and fetal goals are conflicting. For instance,
ECMO has been used for pregnancy prolongation in
the context of maternal brain death and extreme pre-
maturity,102 a scenario where the mother is rendered
an instrument for fetal survival. In such instances,
the International Federation of Gynecology and
Obstetrics (FIGO) emphasizes that decisions around
pregnancy prolongation be informed by anticipated
fetal outcomes as well as known maternal wishes, or
at least the wishes of their family.103 In these ethically
ambiguous and uncommon scenarios, palliative care
and clinical ethics consultation help to identify shared
goals and enhance communication.
CONCLUSIONS
ECMO is an effective rescue therapy for pregnant and
postpartum patients with severe cardiopulmonary
dysfunction, and it has been increasingly utilized
over the past 2 decades. Maternal and fetal outcomes
after ECMO support have steadily improved during
this time, and ongoing experience with this form of
life support will continue to inform practice. Survival
can be bolstered by early recognition of maternal
critical illness and referral to a specialized center
with expertise in ECMO and high-risk obstetrics.
Multidisciplinary collaboration is essential given the
complex interplay of maternal and ECMO physiol-
ogy. E
286   
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ACKNOWLEDGMENTS
The authors thank Sahana Bharadwaj for producing
schematics to demonstrate ECMO cannula configura-
tions and padding for prone positioning.
DISCLOSURES
Name: Michael J. Wong, MD.
Contribution: This author helped draft, edit, and
approve the final manuscript.
Name: Shobana Bharadwaj, MBBS.
Contribution: This author helped draft, edit, and
approve the final manuscript.
Name: Jessica L. Galey, MD.
Contribution: This author helped draft, edit, and
approve the final manuscript.
Name: Allison S. Lankford, MD.
Contribution: This author helped draft, edit, and
approve the final manuscript.
Name: Samuel Galvagno, DO, PhD.
Contribution: This author helped draft, edit, and
approve the final manuscript.
Name: Bhavani Shankar Kodali, MD.
Contribution: This author helped conceive, draft, edit,
and approve the final manuscript.
This manuscript was handled by: Jill M. Mhyre, MD.
REFERENCES
1. Naoum EE, Chalupka A, Haft J, et al. Extracorporeal life
support in pregnancy: a systematic review. J Am Heart
Assoc. 2020;9:e016072.
2. Creanga AA, Syverson C, Seed K, Callaghan WM.
Pregnancy-related mortality in the United States, 2011–
2013. Obstet Gynecol. 2017;130:366–373.
3. Cristina Rossi A, Mullin P. The etiology of maternal mortal-
ity in developed countries: a systematic review of literature.
Arch Gynecol Obstet. 2012;285:1499–1503.
4. Extracorporeal Life Support Organization. ELSO guidelines
for cardiopulmonary extracorporeal life support, version
1.4. 2017.
5. Tonna JE, Abrams D, Brodie D, et al. Management of
adult patients supported with venovenous extracorporeal
membrane oxygenation (VV ECMO): guideline from the
Extracorporeal Life Support Organization (ELSO). ASAIO
J. 2021;67:601–610.
6. Mehta LS, Warnes CA, Bradley E, et al; American Heart
Association Council on Clinical Cardiology; Council on
Arteriosclerosis, Thrombosis and Vascular Biology; Council
on Cardiovascular and Stroke Nursing; and Stroke Council.
Cardiovascular considerations in caring for pregnant
patients: a scientific statement from the American Heart
Association. Circulation. 2020;141:e884–e903.
7. American College of Obstetricians and Gynecologists’
Presidential Task Force on Pregnancy and Heart Disease.
ACOG practice bulletin no. 212: pregnancy and heart dis-
ease. Obstet Gynecol. 2019;133:e320–e356.
8. Cheng V, Abdul-Aziz MH, Roberts JA, Shekar K. Optimising
drug dosing in patients receiving extracorporeal membrane
oxygenation. J Thorac Dis. 2018;10:S629–S641.
9. Guntupalli KK, Karnad DR, Bandi V, Hall N, Belfort M.
Critical illness in pregnancy: part II: common medical con-
ditions complicating pregnancy and puerperium. Chest.
2015;148:1333–1345.
10. Guntupalli KK, Hall N, Karnad DR, Bandi V, Belfort M.
Critical illness in pregnancy: part I: an approach to a
ANESTHESIA & ANALGESIA
 E  Narrative Review Article
pregnant patient in the ICU and common obstetric disor-
ders. Chest. 2015;148:1093–1104.
11. Price LC, Slack A, Nelson-Piercy C. Aims of obstetric criti-
cal care management. Best Pract Res Clin Obstet Gynaecol.
2008;22:775–799.
12. Zieleskiewicz L, Chantry A, Duclos G, et al. Intensive
care and pregnancy: epidemiology and general prin-
ciples of management of obstetrics ICU patients during
pregnancy. Anaesth Crit Care Pain Med. 2016;35(suppl
1):S51–S57.
13. Simsek Y, Ciplak B, Songur S, Kara M, Karahocagil MK.
Maternal and fetal outcomes of COVID-19, SARS, and
MERS: a narrative review on the current knowledge. Eur
Rev Med Pharmacol Sci. 2020;24:9748–9752.
14. Ong J, Zhang JJY, Lorusso R, MacLaren G, Ramanathan K.
Extracorporeal membrane oxygenation in pregnancy and
the postpartum period: a systematic review of case reports.
Int J Obstet Anesth. 2020;43:106–113.
15. Ramanathan K, Tan CS, Rycus P, et al. Extracorporeal mem-
brane oxygenation in pregnancy: an analysis of the extra-
corporeal life support organization registry. Crit Care Med.
2020;48:696–703.
16. Saad AF, Rahman M, Maybauer DM, et al. Extracorporeal
membrane oxygenation in pregnant and postpartum
women with H1N1-related acute respiratory distress syn-
drome: a systematic review and meta-analysis. Obstet
Gynecol. 2016;127:241–247.
17. Thiagarajan RR, Barbaro RP, Rycus PT, et al; ELSO Member
Centers. Extracorporeal life support organization registry
international report 2016. ASAIO J. 2017;63:60–67.
18. Lankford AS, Chow JH, Jackson AM, et al. Clinical outcomes
of pregnant and postpartum extracorporeal membrane oxy-
genation patients. Anesth Analg. 2021;132:777–787.
19. Ngatchou W, Ramadan AS, Van Nooten G, Antoine M. Left
tilt position for easy extracorporeal membrane oxygen-
ation cannula insertion in late pregnancy patients. Interact
Cardiovasc Thorac Surg. 2012;15:285–287.
20. Yau P, Xia Y, Shariff S, et al. Factors associated with ipsilat-
eral limb ischemia in patients undergoing femoral cannula-
tion extracorporeal membrane oxygenation. Ann Vasc Surg.
2019;54:60–65.
21. Ranney DN, Benrashid E, Meza JM, et al. Vascular compli-
cations and use of a distal perfusion cannula in femorally
cannulated patients on extracorporeal membrane oxygen-
ation. ASAIO J. 2018;64:328–333.
22. Agerstrand C, Abrams D, Biscotti M, et al. Extracorporeal
membrane oxygenation for cardiopulmonary failure dur-
ing pregnancy and postpartum. Ann Cardiothorac Surg.
2016;102:774–779.
23. Society for Maternal-Fetal Medicine, Plante LA, Pacheco
LD, Louis JM. SMFM Consult Series #47: sepsis dur-
ing pregnancy and the puerperium. Am J Obstet Gynecol.
2019;220:B2–B10.
24. Lapinsky SE, Rojas-Suarez JA, Crozier TM, et al. Mechanical
ventilation in critically-ill pregnant women: a case series.
Int J Obstet Anesth. 2015;24:323–328.
25. Lapinsky SE. Acute respiratory failure in pregnancy. Obstet
Med. 2015;8:126–132.
26. Tomlinson MW, Caruthers TJ, Whitty JE, Gonik B. Does
delivery improve maternal condition in the respiratory-
compromised gravida? Obstet Gynecol. 1998;91:108–111.
27. Alyamani O, Mazzeffi MA, Bharadwaj S, et al. Venovenous
extracorporeal membrane oxygenation to prolong preg-
nancy: a case report. A A Pract. 2018;10:229–231.
28. Pacheco LD, Saad AF, Saade G. Early acute respiratory sup-
port for pregnant patients with coronavirus disease 2019
(COVID-19) infection. Obstet Gynecol. 2020;136:42–45.
August 2022 • Volume 135 • Number 2
Copyright © 2022 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
29. Tolcher MC, McKinney JR, Eppes CS, et al. Prone position-
ing for pregnant women with hypoxemia due to coronavirus
disease 2019 (COVID-19). Obstet Gynecol. 2020;136:259–261.
30. Bobrowski RA. Pulmonary physiology in pregnancy. Clin
Obstet Gynecol. 2010;53:285–300.
31. Muench MV, Canterino JC. Trauma in pregnancy. Obstet
Gynecol Clin North Am. 2007;34:555–583, xiii.
32. Nunes LB, Mendes PV, Hirota AS, et al; ECMO Group.
Severe hypoxemia during veno-venous extracorporeal
membrane oxygenation: exploring the limits of extracorpo-
real respiratory support. Clinics (Sao Paulo). 2014;69:173–178.
33. Biderman P, Carmi U, Setton E, Fainblut M, Bachar O, Einav
S. Maternal salvage with extracorporeal life support: lessons
learned in a single center. Anesth Analg. 2017;125:1275–1280.
34. Guarracino F, Zangrillo A, Ruggeri L, et al. β-blockers to
optimize peripheral oxygenation during extracorporeal
membrane oxygenation: a case series. J Cardiothorac Vasc
Anesth. 2012;26:58–63.
35. Nair P, Davies AR, Beca J, et al. Extracorporeal membrane
oxygenation for severe ARDS in pregnant and postpartum
women during the 2009 H1N1 pandemic. Intensive Care
Med. 2011;37:648–654.
36. Pacheco LD, Sherwood ER. Trauma and critical care.
In: Chestnut DH, ed. Chestnuts Obstetric Anesthesia:
Principles and Practice. 6th ed. Elsevier; 2020.
37. Hegewald MJ, Crapo RO. Respiratory physiology in preg-
nancy. Clin Chest Med. 2011;32:1–13.
38. Omo-Aghoja L. Maternal and fetal acid-base chemistry: a
major determinant of perinatal outcome. Ann Med Health
Sci Res. 2014;4:8–17.
39. Martin CB Jr. Normal fetal physiology and behavior, and
adaptive responses with hypoxemia. Semin Perinatol.
2008;32:239–242.
40. Lapinsky SE, Posadas-Calleja JG, McCullagh I. Clinical
review: ventilatory strategies for obstetric, brain-injured
and obese patients. Crit Care. 2009;13:206.
41. Ivankovic AD, Elam JO, Huffman J. Effect of maternal
hypercarbia on the newborn infant. Am J Obstet Gynecol.
1970;107:939–946.
42. Bandi VD, Munnur U, Matthay MA. Acute lung injury and
acute respiratory distress syndrome in pregnancy. Crit Care
Clin. 2004;20:577–607.
43. Motoyama EK, Rivard G, Acheson F, Cook CD. Adverse
effect of maternal hyperventilation on the foetus. Lancet.
1966;1:286–288.
44. Levinson G, Shnider SM, DeLorimier AA, Steffenson JL.
Effects of maternal hyperventilation on uterine blood flow
and fetal oxygenation and acid-base status. Anesthesiology.
1974;40:340–347.
45. Deatrick KB, Mazzeffi MA, Galvagno SM Jr, et al. Breathing
life back into the kidney-continuous renal replacement
therapy and veno-venous extracorporeal membrane oxy-
genation. ASAIO J. 2021;67:208–212.
46. Rooth G, McBride R, Ivy BJ. Fetal and maternal pH mea-
surements. A basis for common normal values. Acta Obstet
Gynecol Scand. 1973;52:47–50.
47. Baraka A. Correlation between maternal and foetal
PO2 and PCO2 during caesarean section. Br J Anaesth.
1970;42:434–438.
48. The Acute Respiratory Distress Syndrome Network.
Ventilation with lower tidal volumes as compared with
traditional tidal volumes for acute lung injury and
the acute respiratory distress syndrome. N Engl J Med.
2000;342:1301–1308.
49. Talmor D, Sarge T, Malhotra A, et al. Mechanical ventilation
guided by esophageal pressure in acute lung injury. N Engl
J Med. 2008;359:2095–2104.
www.anesthesia-analgesia.org 287
 ECMO for Obstetric Patients
50. Rojas-Suarez JA, Miranda J. Mechanical ventilation in preg-
nancy. In: Lapinsky SE, Plante LA, eds. Respiratory Disease in
Pregnancy. Cambridge University Press, 2020:233–244.
51. Jenks CL, Tweed J, Gigli KH, Venkataraman R, Raman L.
An international survey on ventilator practices among
extracorporeal membrane oxygenation centers. ASAIO J.
2017;63:787–792.
52. Menaker J, Dolly K, Rector R, et al. The lung rescue unit—
does a dedicated intensive care unit for venovenous extra-
corporeal membrane oxygenation improve survival to
discharge? J Trauma Acute Care. 2017;83:438–442.
53. Tabatabai A, Galvagno SM Jr, O’Connor JV, Scalea TM,
Deatrick KB. Extracorporeal life support (ECLS): a
review and focus on considerations for COVID-19. Shock.
2021;55:742–751.
54. Galvagno SM Jr, Pelekhaty S, Cornachione CR, et al. Does
weight matter? Outcomes in adult patients on venovenous
extracorporeal membrane oxygenation when stratified by
obesity class. Anesth Analg. 2020;131:754–761.
55. Urner M, Jüni P, Hansen B, Wettstein MS, Ferguson ND,
Fan E. Time-varying intensity of mechanical ventilation
and mortality in patients with acute respiratory failure: a
registry-based, prospective cohort study. Lancet Respir Med.
2020;8:905–913.
56. Amato MB, Meade MO, Slutsky AS, et al. Driving pressure
and survival in the acute respiratory distress syndrome. N
Engl J Med. 2015;372:747–755.
57. Nieman GF, Gatto LA, Andrews P, et al. Prevention and
treatment of acute lung injury with time-controlled adap-
tive ventilation: physiologically informed modification
of airway pressure release ventilation. Ann Intensive Care.
2020;10:3.
58. Aoyama H, Uchida K, Aoyama K, et al. Assessment of
therapeutic interventions and lung protective ventilation in
patients with moderate to severe acute respiratory distress
syndrome: a systematic review and network meta-analysis.
JAMA Netw Open. 2019;2:e198116.
59. Patel B, Arcaro M, Chatterjee S. Bedside troubleshooting
during venovenous extracorporeal membrane oxygenation
(ECMO). J Thorac Dis. 2019;11:S1698–S1707.
60. Kredel M, Bischof L, Wurmb TE, Roewer N, Muellenbach
RM. Combination of positioning therapy and venovenous
extracorporeal membrane oxygenation in ARDS patients.
Perfusion. 2014;29:171–177.
61. Lucchini A, De Felippis C, Pelucchi G, et al. Application of
prone position in hypoxaemic patients supported by veno-
venous ECMO. Intensive Crit Care Nurs. 2018;48:61–68.
62. Kenn S, Weber-Carstens S, Weizsaecker K, Bercker S. Prone
positioning for ARDS following blunt chest trauma in late
pregnancy. Int J Obstet Anesth. 2009;18:268–271.
63. Cole DE, Taylor TL, McCullough DM, Shoff CT, Derdak S.
Acute respiratory distress syndrome in pregnancy. Crit Care
Med. 2005;33:S269–S278.
64. Acharya G, Sitras V. Oxygen uptake of the human fetus at
term. Acta Obstet Gynecol Scand. 2009;88:104–109.
65. Cousins L. Fetal oxygenation, assessment of fetal well-
being, and obstetric management of the pregnant patient
with asthma. J Allergy Clin Immunol. 1999;103:S343–S349.
66. Murphy PJ. The fetal circulation. Contin Educ Anaesth Crit
Care Pain. 2005;5:107–112.
67. Venuto RC, Cox JW, Stein JH, Ferris TF. The effect of changes
in perfusion pressure on uteroplacental blood flow in the
pregnant rabbit. J Clin Invest. 1976;57:938–944.
68. Moore SA, Dietl CA, Coleman DM. Extracorporeal life
support during pregnancy. J Thorac Cardiovasc Surg.
2016;151:1154–1160.
288   
www.anesthesia-analgesia.org
Copyright © 2022 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
69. Pacheco LD, Saade GR, Hankins GDV. Extracorporeal
membrane oxygenation (ECMO) during pregnancy and
postpartum. Semin Perinatol. 2018;42:21–25.
70. Carlier L, Devroe S, Budts W, et al. Cardiac interventions in
pregnancy and peripartum - a narrative review of the litera-
ture. J Cardiothorac Vasc Anesth. 2020;34:3409–3419.
71. Champsaur G, Parisot P, Martinot S, et al. Pulsatility
improves hemodynamics during fetal bypass. Experimental
comparative study of pulsatile versus steady flow.
Circulation. 1994;90:II47–II50.
72. Lin TY, Chiu KM, Shieh JS, Chu SH. Emergency redo mitral
valve replacement in a pregnant woman at third trimester:
case report and literature review. Circ J. 2008;72:1715–1717.
73. Mazzeffi M. Patient blood management in adult extracor-
poreal membrane oxygenation patients. Curr Anesthesiol
Rep. 2020;10:147–156.
74. Extracorporeal Life Support Organization. ELSO anticoag-
ulation guideline. 2014.
75. Abbasciano RG, Yusuff H, Vlaar APJ, Lai F, Murphy GJ.
Blood transfusion threshold in patients receiving extra-
corporeal membrane oxygenation support for cardiac and
respiratory failure-a systematic review and meta-analysis. J
Cardiothorac Vasc Anesth. 2021;35:1192–1202.
76. Balle CM, Jeppesen AN, Christensen S, Hvas AM. Platelet
function during extracorporeal membrane oxygenation in
adult patients. Front Cardiovasc Med. 2019;6:114.
77. Jiritano F, Serraino GF, Ten Cate H, et al. Platelets and
extra-corporeal membrane oxygenation in adult patients:
a systematic review and meta-analysis. Intensive Care Med.
2020;46:1154–1169.
78. Singh G, Nahirniak S, Arora R, et al. Transfusion thresholds
for adult respiratory extracorporeal life support: an expert
consensus document. Can J Cardiol. 2020;36:1550–1553.
79. Sniderman J, Monagle P, Annich GM, MacLaren G.
Hematologic concerns in extracorporeal membrane oxy-
genation. Res Pract Thromb Haemost. 2020;4:455–468.
80. Hellgren M. Hemostasis during normal pregnancy and
puerperium. Semin Thromb Hemost. 2003;29:125–130.
81. Esper SA, Levy JH, Waters JH, Welsby IJ. Extracorporeal
membrane oxygenation in the adult: a review of anti-
coagulation monitoring and transfusion. Anesth Analg.
2014;118:731–743.
82. Fogerty AE. Challenges of anticoagulation therapy in preg-
nancy. Curr Treat Options Cardiovasc Med. 2017;19:76.
83. Quintel M, Bartlett RH, Grocott MPW, et al. Extracorporeal
membrane oxygenation for respiratory failure.
Anesthesiology. 2020;132:1257–1276.
84. Huang KY, Li YP, Lin SY, Shih JC, Chen YS, Lee CN.
Extracorporeal membrane oxygenation application in post-
partum hemorrhage patients: is post-partum hemorrhage
contraindicated? J Obstet Gynaecol Res. 2017;43:1649–1654.
85. Kurihara C, Walter JM, Karim A, et al. Feasibility of
venovenous extracorporeal membrane oxygenation
without systemic anticoagulation. Ann Thorac Surg.
2020;110:1209–1215.
86. Olson SR, Murphree CR, Zonies D, et al. Thrombosis and
bleeding in extracorporeal membrane oxygenation (ECMO)
without anticoagulation: a systematic review. ASAIO J.
2021;67:290–296.
87. Weber C, Deppe AC, Sabashnikov A, et al. Left ventricular
thrombus formation in patients undergoing femoral veno-
arterial extracorporeal membrane oxygenation. Perfusion.
2018;33:283–288.
88. Makdisi G, Hashmi ZA, Wozniak TC, Wang IW. Left ventric-
ular thrombus associated with arteriovenous extra corpo-
real membrane oxygenation. J Thorac Dis. 2015;7:E552–E554.
ANESTHESIA & ANALGESIA
 E  Narrative Review Article
89. Lorusso R, Shekar K, MacLaren G, et al. ELSO interim guide-
lines for venoarterial extracorporeal membrane oxygen-
ation in adult cardiac patients. ASAIO J. 2021;67:827–844.
90. Sagaram D, Siddiq Z, Eisenberger AB, et al. Heparin-
induced thrombocytopenia during obstetric hospital
admissions. Am J Perinatol. 2018;35:898–903.
91. Pollak U. Heparin-induced thrombocytopenia complicat-
ing extracorporeal membrane oxygenation support: review
of the literature and alternative anticoagulants. J Thromb
Haemost. 2019;17:1608–1622.
92. Ekbatani A, Asaro LR, Malinow AM. Anticoagulation with
argatroban in a parturient with heparin-induced thrombo-
cytopenia. Int J Obstet Anesth. 2010;19:82–87.
93. Mauermann E, Vökt C, Tsakiris DA, Tobler D, Girard T.
Heparin-induced thrombocytopenia in pregnancy: an inter-
disciplinary challenge-a case report and literature review.
Int J Obstet Anesth. 2016;26:79–82.
94. Menaker J, Tabatabai A, Rector R, et al. Incidence of cannula-
associated deep vein thrombosis after veno-venous extracor-
poreal membrane oxygenation. ASAIO J. 2017;63:588–591.
95. Bidar F, Lancelot A, Lebreton G, et al. Venous or arterial
thromboses after venoarterial extracorporeal membrane
oxygenation support: frequency and risk factors. J Heart
Lung Transplant. 2021;40:307–315.
96. Broman LM, Malfertheiner MV, Montisci A, Pappalardo F.
Weaning from veno-venous extracorporeal membrane oxy-
genation: how I do it. J Thorac Dis. 2018;10:S692–S697.
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Copyright © 2022 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
97. Swol J, Shekar K, Protti A, et al. Extubate before veno-
venous extracorporeal membranous oxygenation
decannulation or decannulate while remaining on the
ventilator? The EuroELSO 2019 weaning survey. ASAIO
J. 2021;67:e86–e89.
98. Grant AA, Hart VJ, Lineen EB, et al. A weaning pro-
tocol for venovenous extracorporeal membrane oxy-
genation with a review of the literature. Artif Organs.
2018;42:605–610.
99. Esmaeilzadeh M, Dictus C, Kayvanpour E, et al. One
life ends, another begins: management of a brain-dead
pregnant mother-a systematic review-. BMC Med.
2010;8:74.
100. Townsend SF. Ethics for the pediatrician: obstetric con-
flict: when fetal and maternal interests are at odds. Pediatr
Rev. 2012;33:33–37.
101. Mallampalli A, Guy E. Cardiac arrest in pregnancy
and somatic support after brain death. Crit Care Med.
2005;33:S325–S331.
102. Salazar L, Arora L, Botia M, et al. Somatic support with
veno-venous ECMO in a pregnant woman with brain
death: a case report. ASAIO J. Published online Mar 11,
2021. doi: 10.1097/mat.0000000000001411.
103. FIGO Committee for the Ethical Aspects of Human
Reproduction and Women’s Health. Brain death and
pregnancy. Int J Gynaecol Obstet. 2011;115:84–85.
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