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Extracorporeal membrane oxygenation in pregnancy: details on novel therapies and cardiac, preeclampsia, and mood disorder complications

Published:January 19, 2022DOI:https://doi.org/10.1016/j.ajog.2022.01.009
      We thank Sarkar et al for their interest in our findings and thoughtful questions regarding therapeutics and complications in our study entitled, “Extracorporeal membrane oxygenation in pregnancy: a bridge to delivery and pulmonary recovery for COVID-19-related severe respiratory failure.”
      • Yin O.
      • Richley M.
      • Hadaya J.
      • et al.
      Extracorporeal membrane oxygenation in pregnancy: a bridge to delivery and pulmonary recovery for COVID-19-related severe respiratory failure.
      Regarding therapies, 3 out of the 5 patients were given convalescent plasma and 2 out of the 5 were administered tocilizumab. The criteria for initiation of convalescent plasma treatment at our center at that time was a SARS-CoV-2 infection requiring hospitalization, and the criteria for initiation of tocilizumab was a new-onset requirement for oxygen supplementation with the ability to start tocilizumab within 72 hours of starting oxygen supplementation.
      • Gupta S.
      • Wang W.
      • Hayek S.S.
      • et al.
      Association between early treatment with tocilizumab and mortality among critically ill patients with COVID-19.
      A contraindication for tocilizumab treatment was a history of organ transplant. The patients who were given convalescent plasma were cases 1, 2, and 4 and those given tocilizumab were 1 and 5. This and additional information on COVID-19 treatment are published with Supplemental Table 1 in the final version of this article.
      Patient 4 had an episode of long sinus arrest on hospital day (HD) 45, which corresponded to extracorporeal membrane oxygenation (ECMO) day 39 of 68. The ECMO circuit clotted and required exchange with development of a severe left-sided pneumothorax shortly thereafter, leading to hypoxia and associated bradycardia and subsequently cardiac arrest. The patient improved after chest tube placement and cardiopulmonary resuscitation with no further cardiac events.
      Both patients 1 and 3 developed hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome. Patient 1 did not have liver enzyme complications, but she did have severe range blood pressures and decreasing platelet counts, as low as 96 mg/dL, which prompted her cesarean delivery. Patient 3 had worsening liver enzymes as early as HD 19, peaking on HD 25 with aspartate aminotransferase levels at 895 U/L, alanine aminotransferase levels at 743 U/L, and lactate dehydrogenase levels at 1302 U/L with continued hypertension requiring labetalol. The diagnosis of HELLP was definitively made retrospectively in both patients after observing rapid improvements in their laboratory results and blood pressures postpartum. In the antepartum period, other differential diagnoses for thrombocytopenia included ECMO-related shear stress and membrane absorption of key platelet factors,
      • Sniderman J.
      • Monagle P.
      • Annich G.M.
      • MacLaren G.
      Hematologic concerns in extracorporeal membrane oxygenation.
      preeclampsia-like syndrome observed in severe COVID-19 infection,
      • Mendoza M.
      • Garcia-Ruiz I.
      • Maiz N.
      • et al.
      Pre-eclampsia-like syndrome induced by severe COVID-19: a prospective observational study.
      and heparin-induced thrombocytopenia, making it more difficult to diagnose HELLP and proceed toward delivery in pregnant patients on ECMO.
      Mood disorders were common after ECMO in pregnancy. Patient 1 developed depression with significant triggers related to the inability to breastfeed after decannulation. She did not require medications and received psychosocial counseling. An outpatient psychiatry follow-up at 3 months postpartum was attempted, but because of telemedicine connectivity issues, this was not completed. Patient 3 had anxiety requiring trazodone and sertraline and was doing well at the 1-month follow-up. Patient 4 developed insomnia and was started on quetiapine and gabapentin with a stable mood at the 1-month follow-up and a plan for outpatient posttraumatic stress therapy. We agree that long-term follow-up of postpartum mood disorders, especially after an intensive care unit admission during the peripartum period, is needed and recent studies have confirmed an association between psychiatric disorders and COVID-19 infection.
      • Taquet M.
      • Luciano S.
      • Geddes J.R.
      • Harrison P.J.
      Bidirectional associations between COVID-19 and psychiatric disorder: retrospective cohort studies of 62354COVID -19cases in the USA.

      References

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