Extracorporeal membrane oxygenation for pulmonary arterial hypertension complicating pregnancy: case series and literature review

BACKGROUND: Pregnancy-associated pulmonary arterial hypertension (PAH) remains a life-threatening condition with high maternal mortality, primarily due to peripartum right heart failure and hemodynamic collapse. Although extracorporeal membrane oxygenation (ECMO) has emerged as a critical rescue therapy for refractory cardiopulmonary failure in this population, evidence guiding its optimal application—including modality selection, initiation timing, and anticoagulation management—remains fragmented. This study aimed to synthesize real - world experience and published evidence to clarify ECMO’s role in improving outcomes for pregnant/postpartum patients with severe PAH. CASE PRESENTATION: We retrospectively analyzed 5 institutional cases of severe PAH in pregnant/postpartum patients who received veno - arterial (VA) ECMO support (July 2020–September 2025) and integrated these with 31 literature - derived cases (2000–August 2025), totaling 36 patients. The institutional cases included: (1) A 24 - year - old patient with post - ventricular septal defect (VSD) repair and systemic lupus erythematosus (SLE) who died of brainstem failure despite 22 days of VA ECMO; (2) A 19 - year - old patient with patent ductus arteriosus (PDA) and bidirectional shunting, who required ECMO reinitiation but ultimately recovered after 53 days of support; (3) A 35 - year - old patient with congenital heart disease (VSD) who was successfully weaned off ECMO after 2 days; (4) A 24 - year - old patient with atrial septal defect (ASD) and cardiac arrest, who recovered following 49 days of VA ECMO and continuous renal replacement therapy (CRRT); (5) A 28 - year - old patient with ASD and Eisenmenger syndrome, who survived 45 days of ECMO despite septicemia. Across all 36 cases, the median maternal age was 30.8 ± 5.6 years, 96.4% (35/36) underwent cesarean section, and VA ECMO was the dominant modality (70.9%, 25/36). CONCLUSION: VA ECMO is a viable rescue therapy for pregnant/postpartum patients with severe PAH and hemodynamic instability, achieving a maternal survival rate of 58.1% (21/36) in this cohort. Preemptive ECMO initiation and multidisciplinary collaboration (involving obstetricians, cardiologists, and ECMO specialists) are critical for optimizing outcomes. VV ECMO should be restricted to patients with isolated hypoxemia and preserved right ventricular function.