Abstract
Acute respiratory distress syndrome (ARDS) in pregnancy is rare but life-threatening. Extracorporeal membrane oxygenation (ECMO) has been used as rescue therapy in refractory cases, though evidence remains limited. This systematic review aimed to synthesize maternal and neonatal outcomes, describe complications, and evaluate study quality to inform clinical practice and research. A comprehensive search of MEDLINE, Embase, and Cochrane databases, through May 28, 2025, identified observational studies and case series reporting ECMO use for ARDS during pregnancy or the postpartum period. Two reviewers independently screened studies, extracted data, and assessed risk of bias using the Newcastle-Ottawa Scale (NOS) for cohorts and the Joanna Briggs Institute (JBI) checklist for case series. Thirteen studies published between 2011 and 2024 were included, most involving venovenous (VV) ECMO. Maternal survival ranged from 33% to 100%, with larger and more recent series reporting survival exceeding 80%. Major complications included bleeding, thromboembolism, infection, and acute kidney injury. Fetal outcomes were strongly influenced by gestational age at ECMO initiation, and neonatal morbidity largely reflected the degree of prematurity. The overall risk of bias was moderate to high across most studies. In conclusion, ECMO can be lifesaving for pregnant and postpartum patients with refractory ARDS, but current evidence is constrained by observational designs, small sample sizes, and heterogeneity in reporting. Standardized data collection, prospective registries, and collaborative multicenter studies are needed to better define the safety, timing, and long-term outcomes of ECMO use in this unique patient population.