Copyright © 2016 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited. March 1, 2017 • Volume 8 • Number 5 cases-anesthesia-analgesia.org 105 Copyright © 2016 International Anesthesia Research Society DOI: 10.1213/XAA.0000000000000441 T raditionally, extracorporeal membrane oxygenation (ECMO) is utilized for patients requiring respiratory support, patients with acute or chronic heart failure, and/or as a bridge to recovery or until another interven- tion becomes available. Over the past several years, ECMO has been successfully utilized in nonpregnant patients with cardiac and/or respiratory failure, 1 as well as in pregnant patients with respiratory failure with associated improved outcomes. 2 The indications for ECMO in parturients, as well as its surgical implementation, may be diffcult to establish in emergency situations because of complex diagnostic decision making from a diverse array of obstetrical, anes- thesia, and surgical consultants. The utilization of “stand- by” ECMO in high-risk parturients during dilation and evacuation (D&E), vaginal deliveries, or cesarean delivery is not yet considered a standard treatment modality for par- turients with severe cardiac dysfunction. The proven utility and indications for ECMO in the parturient population are still evolving and not clearly defned. Past descriptions of ECMO for use in high-risk par- turients are limited to a number of case reports during pregnancy, delivery, or postdelivery. 3–6 One review demon- strated maternal and fetal survival rates of 80% and 70%, respectively, with utilization of ECMO for pulmonary and cardiac indications. 4 However, in only 2 of these cases was ECMO instituted as a “stand-by” measure, 3,6 and no reports of ECMO use during D&E have been documented. Another report described utilization of ECMO postcesarean delivery for stress-induced cardiomyopathy, 5 and none of the cases had a history of known prepregnancy cardiomyopathy. We present a case of “stand-by” ECMO during a high-risk preg- nancy, which has not been previously described. This case report details a 40-year-old woman with known history of cardiomyopathy, complicated by long-term history of acute and chronic methamphetamine use who presented to our institution with an unknown triplet pregnancy. The patient was scheduled for elective D&E with utilization of “stand- by” ECMO during the surgical procedure. Institutional review board approval was obtained; the patient reviewed this case report and provided written consent for the publi- cation of this case. CASE DESCRIPTION A 40-year-old Hispanic woman (height: 162 cm; weight: 112 kg; body mass index: 42.7 kg/cm 2 ; gravida 10, para 9, miscarriage 1) with a known history of cardiomyopathy and a recently diagnosed triplet pregnancy at 20 weeks’ gesta- tion was transferred to our institution for management from a small community hospital. The patient initially presented to the emergency department at another facility 3 days ear- lier with shortness of breath, lower extremity swelling, and severe hypertension documented for over 2 hours (systolic blood pressure range 200–240 mm Hg; diastolic blood pres- sure range 98–111 mm Hg). Parturients may present with evidence of acute heart failure or respiratory distress during the peripartum period. This case report documents utilization of “stand-by” extracorporeal mem- brane oxygenation (ECMO) for a 40-year-old woman with a history of severe left ventricular dys- function who presented for elective dilation and evacuation of triplets at 20 weeks’ gestation. The patient’s medical history was signifcant for hypertension, diabetes mellitus, methamphet- amine use (acute/chronic), and cardiac-respiratory arrest before her previous emergent cesar- ean delivery. The patient underwent general anesthesia with the placement of peripheral venous and arterial cannulas for “stand-by” ECMO. The patient remained stable throughout the proce- dure, and “stand-by” ECMO was not initiated; the patient was discharged 5 days’ postprocedure. The use of “stand-by” ECMO in the parturient with severe cardiopulmonary dysfunction is still in its infancy. Centers managing populations of both high-risk parturients and nonparturients may consider development of algorithms for implementation and utilization of ECMO. (A&A Case Reports. 2017;8:105–8.) From the *Department of Anesthesiology, Brigham and Women’s Hospital, Boston, Massachusetts; †Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California; ‡Department of Anes- thesiology, Cedars-Sinai Medical Center, Los Angeles, California; §Depart- ment of Surgery, Division of Cardiac Surgery, The Heart Institute, Cedars- Sinai Medical Center, Los Angeles, California; ‖Division of Cardiovascular Medicine, University of Michigan Medical Center, Ann Arbor, Michigan; and ¶Department of Obstetrics, University of California, Irvine Medical Center, Irvine, California. Accepted for publication April 18, 2016. Funding: None. The authors declare no conficts of interest. Address correspondence to Antonio Hernandez Conte, MD, MBA, Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd, 1st Floor, Los Angeles, CA 90027. Address e-mail to Antonio.conte@kp.org. Utilization of “Stand-By” Extracorporeal Membrane Oxygenation in a High-Risk Parturient With Methamphetamine-Associated Cardiomyopathy Undergoing Dilation and Evacuation: A Case Report Cesar Padilla, MD,* Antonio Hernandez Conte, MD, MBA,†‡ Danny Ramzy, MD,§ Lorraine Lubin, MD,‡ Troy LaBounty, MD,‖ Judith H. Chung, MD,¶ and Ying Zeng, MD‡ CASE REPORT E