استمرار الحمل لعدة اسابيع او شهور حتى ولادة اطفال طبيعيين من امهات تم تشخيصهن
( موتى مخياً )

Reprod Health. 2006 Apr 27;3:3.

The prolongation of somatic support in a pregnant woman with brain-death: a case report

Souza JP, Oliveira-Neto A, Surita FG, Cecatti JG, Amaral E, Pinto e Silva JL.

Intensive Care Unit, Department of Obstetrics and Gynecology, School of Medical Sciences, State University of Campinas, Campinas, São Paulo, Brazil. souzajpd@unicamp.br

BACKGROUND: Medical literature has increasingly reported cases of maternal brain death during pregnancy. This is a rare situation which demands the decision and, depending on the gestational age, the implementation of a set of measures to prolong the homeostasis of the human body after brain death for the purpose of maintaining the foetus alive until its viability. CASE PRESENTATION: A 40 year old woman suffered an intracranial haemorrhage during the 25th week of pregnancy. Despite neurosurgical drainage of a gross intraparenchymatous haematoma, the patient developed brain death. Upon confirmation of this diagnosis, she received full ventilatory and nutritional support, vasoactive drugs, maintenance of normothermia, hormone replacement and other supportive measures required to prolong gestation and improve the survival prognosis of her foetus. All decisions regarding the patient's treatment were taken in consensus with her family. She also received corticosteroids to accelerate foetal lung maturity. During the twenty-five days of somatic support, the woman's condition remained stable; however, during the last seven days the foetus developed oligohydramnios and brain-sparring, which led the medical team to take the decision to perform a Caesarean section at that moment. After delivery, the patient's organs were removed for donation. The male infant was born weighing 815 g, with an Apgar score of 9 and 10 at the first and fifth minutes, respectively. The infant was admitted to the neonatal intensive care unit, but did not require mechanical ventilation and had no major complications. He was discharged at 40 days of life, with no sequelae and weighing 1850 g. CONCLUSION: These results are in accordance with findings from previous studies and case reports suggesting the appropriateness and safety of extended somatic support during pregnancy under certain circumstances. They also suggest the need for prompt diagnosis of brain death before the occurrence of physiological degeneration, rapid evaluation of foetal status and the decision of the family together with the medical team to prolong maternal somatic support. The occurrence of maternal brain death is a tragedy, but it may also represent a challenging opportunity to save the life of the foetus and, in addition, permit donation of the maternal organs.

__________________________________________________________

Obstet Gynecol Surv. 2000 Nov;55(11):708-14

Irreversible maternal brain injury during pregnancy: a case report and review of the literature
Feldman DM, Borgida AF, Rodis JF, Campbell WA.

Department of Obstetrics and Gynecology, University of Connecticut Health Center, Farmington 06030-2950, USA. dfeldman@nso2.uchc.edu

Maternal brain death or massive injury leading to persistent vegetative state during pregnancy is a rare event. Since 1979, 11 cases, including the current one, of irreversible maternal brain damage in pregnancy have been reported. In all but one, the pregnancies were prolonged with a goal of achieving delivery of a viable infant. Current advances in medicine and critical care enable today's physician to offer prolonged life-support to maximize the chances for survival in the neonate whose mother is technically brain dead. We present a case at our institution and review all previously published cases in the English literature for comparison as well as make management recommendations .

__________________________________________________________

Journal of the American Medical Association

JAMA. 1988 Aug 12;260(6):816-22.

Maternal brain death during pregnancy. Medical and ethical issues.

Field DR, Gates EA, Creasy RK, Jonsen AR, Laros RK Jr.

Department of Obstetrics, Gynecology, University of California, San Francisco 94143-0132.

We present in detail a case of a 27-year-old primigravida who was maintained in a brain-dead state for nine weeks. An apparently normal and healthy male infant weighing 1440 g was delivered. The newborn did well and was found to be growing and developing normally at 18 months of age. Although the technical aspects of prolonged life support are demanding and the economic costs are very high (+217,784), there are ample ethical arguments justifying the separation of brain death and somatic death and the maintenance of the brain-dead mother so that her unborn fetus can develop and mature.

KIE: Physicians and an ethicist at the University of California, San Francisco, present the details of the case of a pregnant, brain-dead woman whose vital functions were maintained for nine weeks until the delivery of a healthy infant at 31 weeks' gestation. Despite the technical difficulties involved and the economic costs incurred ($183,031 for maternal care and $34,703 for neonatal care), the authors conclude that ethical considerations support the decision on care. They argue that the woman was not injured; that nonmaleficence and beneficence toward the fetus require a rescue attempt if there is a reasonable chance of reaching fetal maturity; that maternal medical care may be more cost effective than prolonged neonatal support; and that the father's wishes were respected. Rather than proposing guidelines, they hold that decisions on prolonged maternal support should be based on the circumstances of each case.

__________________________________________________________

Journal of the American Medical Association

JAMA. 1982 Sep 3;248(9):1089-91

Life support and maternal death during pregnancy

Dillon WP, Lee RV, Tronolone MJ, Buckwald S, Foote RJ.

KIE: The authors are physicians affiliated with the State University of New York at Buffalo and the Children's Hospital of Buffalo. They describe the clinical management of two brain-dead pregnant women and suggest guidelines to help physicians decide whether to treat such women. Based on the dramatically increasing chances for fetal survival from the 24th to the 27th weeks of gestation, they recommend vigorous life support during this period to permit fetal viability and prognosis to be assessed. Fetuses of 28 weeks should be delivered by cesarean section as soon as practicable after confirmation of maternal brain death.
 

__________________________________________________________

Hastings Cent Rep. 1986 Feb;16(1):12-7

On dying more than one death
Shrader D.

Death (with a capital D) can best be understood as a series of distinct but related deaths. For example, a pregnant woman was found to be brain-dead but her vital functions were artificially sustained for nine weeks until her fetus could be delivered, after which the machines were removed and she died a second, conceptually distinct death. This procedure is probably justifiable, but any legislation or policy regarding such cases should be flexible and should require consent.

KIE: It is argued that death should be understood as encompassing a series of distinct but related events. Human beings are viewed as a composite of two intimately related but distinguishable components, as both persons and biological entities. Thus, a brain dead patient can be considered in some sense alive and in some sense dead. This thesis forms the basis for an analysis of a case in which a brain dead pregnant woman's vital functions were artificially sustained until her fetus could be delivered alive, after which the woman's life support systems were disconnected and she ceased breathing. The author holds that this procedure was morally justifiable. He suggests that a multiple-deaths analysis may provide a general framework for discussion of the conditions that justify maintenance of biological functions in neocortically dead human beings, but cautions that any legislation or policy regarding such cases should be flexible and should require consent.
__________________________________________________________

Revista médica de Chile

Rev Med Chil. 1998 Apr;126(4):450-5.

Maternal brain death during pregnancy

[Article in Spanish]

Beca JP, Wells W, Rubio W.

Facultad de Medicina, Universidad de Chile.

The case of a pregnant patient who had a massive intracraneal haemorrhage at 18 weeks of gestation is presented. Patient's neurological damage evolved to brain death, but the fetus continued in good condition. The decision of withdrawing life support or to continue supporting the mother's life to allow fetal development aroused difficult ethical questions, both to relatives and professionals. This is an exceptional situation of a heart beating cadaver and a non viable fetus whose life depends on the continuation of treatments that are considered as experimental. A good decision should be based on the respect to a body in brain death, the fetal right to life, family's wishes and values, the use of experimental treatments, and the rational use of a public hospital's resources. The conclusion was that the continuation of life support treatments was not an ethical obligation. Withdrawing life support to allow fetal death in this case means foregoing an experimental treatment and to respect family's autonomy and the right of the patient's death with dignity. Similar cases need to be discussed with a multidisciplinary analysis in their own particularity.

__________________________________________________________

Crit Care Med. 2003 Apr;31(4):1241-9.

Extended somatic support for pregnant women after brain death.

Powner DJ, Bernstein IM.

Department of Neurosurgery, University of Texas, Houston, TX, USA.

OBJECTIVE: To review case reports of pregnant women who have been supported after brain death until successful delivery of their infants. From these reports and other literature about brain death, normal physiologic changes of pregnancy, and specific needs for fetal development, recommendations were made to assist in supporting pregnant women after brain death until delivery of a mature fetus who is likely to survive.
DATA SOURCES: Personal files and experiences, MEDLINE review of case reports and publications about physiologic changes present during normal pregnancy and after brain death, and the critical needs for fetal development were included. DATA EXTRACTION: Eleven reports of ten patients comprise the accumulated clinical experience. Hypotension, requiring fluid administration and inotropic/vasopressor therapy, occurred in all the mothers, and in six cases, was the reason for urgent delivery. The longest period of support was 107 days, from 15 to 32 wks of gestation. Two mothers also became organ donors. Recurrent infections, thermolability, and other complications common to prolonged ICU care were encountered. All infants survived. One had congenital abnormalities caused by phenytoin use by the mother. When followed, all others developed within normal growth and mental variables. These cases plus literature citations noted above were used to develop recommendations for maternal/fetal care.
CONCLUSION: Preservation of uterine/placental blood flow is the most important priority during somatic support. Imprecise autoregulation of the uterine vasculature during maternal hypoxemia or hypotension makes this goal a significant challenge. Special considerations for nutrition; medication use; cardiovascular, respiratory, or endocrine therapy; fetal monitoring; hormone replacement; and ethical concerns are discussed.

__________________________________________________________

Critical Care Clinics

Crit Care Clin. 2004 Oct;20(4):747-61

Cardiopulmonary resuscitation and somatic support of the pregnant patient.

Mallampalli A, Powner DJ, Gardner MO.

Section of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Ben Taub General Hospital, 1504 Taub Loop, 6th Floor, Houston, TX 77030, USA. antara@bcm.tmc.edu

Cardiopulmonary arrest during pregnancy is a rare event that critical care clinicians must be prepared to manage. The causes of cardiopulmonary arrest during pregnancy, recommended modifications to cardiopulmonary resuscitation protocols that are specific to pregnancy, indications for and timing of perimortem cesarean delivery, and the expected fetal outcomes are reviewed. Rarely, brain death of a pregnant patient may occur in which continued support of the mother is possible to prolong the pregnancy and improve fetal outcome. Prolonged somatic support of pregnant patients who are brain dead presents specific management challenges, but has been accomplished. The physiologic changes that occur after brain death and recommendations for somatic support of the brain dead pregnant patient also are reviewed.

__________________________________________________________

Crit Care Med. 2005 Oct;33(10 Suppl):S325-31.

Cardiac arrest in pregnancy and somatic support after brain death.

Mallampalli A, Guy E.

Section of Pulmonary and Critical Care Medicine, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.

OBJECTIVE: To review the important causes of cardiopulmonary arrest during pregnancy and the recommended modifications to resuscitation protocols when applied to pregnant patients, including the indications for perimortem cesarean section and the expected fetal outcomes, and to review the literature regarding extended somatic support after brain death during pregnancy. DATA SOURCES: MEDLINE review of publications relating to cardiac arrest and resuscitation in pregnancy, physiologic changes after brain death, and attempted somatic support of brain-dead pregnant women. CONCLUSIONS: Cardiac arrest during pregnancy is rare, but it is important to recognize the causes, which may be either unrelated to pregnancy or unique to the pregnant woman. For the most part, the resuscitation protocol is the same as for nonpregnant victims of cardiac arrest, with a few important modifications, including especially the need for relieving aortocaval compression by the gravid uterus, the need for rapid intubation, and the importance of rapid perimortem cesarean delivery when indicated. In those rare cases of brain death occurring in a pregnant patient, continued somatic support of the mother may be possible, even for prolonged periods, to extend the pregnancy and further fetal maturation. The expected physiologic changes after brain death, challenges to successful somatic support, and specific recommendations regarding organ support of the brain-dead pregnant woman are reviewed.

__________________________________________________________

Neurocritical Care

Neurocrit Care. 2005;3(2):99-106

Maternal brain death and somatic support.

Farragher RA, Laffey JG.

Department of Anaesthesia, University College Hospital, and Clinical Sciences Institute, National University of Ireland, Galway, Ireland.

Brain death is a concept used in situations in which life-support equipment obscures the conventional cardiopulmonary criteria of death, and it is legally recognized in most countries worldwide. Brain death during pregnancy is an occasional and tragic occurrence. The mother and fetus are two distinct organisms, and the death of the mother mandates consideration of the well-being of the fetus. Where maternal brain death occurs after the onset of fetal viability, the benefits of prolonging the pregnancy to allow further fetal maturation must be weighed against the risks of continued time in utero, and preparations must be made to facilitate urgent cesarean section and fetal resuscitation at short notice. Where the fetus is nonviable, one must consider whether continuation of maternal organ supportive measures in an attempt to attain fetal viability is appropriate, or whether it constitutes futile care. Although the gestational age of the fetus is central to resolving this issue, there is no clear upper physiological limit to the prolongation of somatic function after brain death. Furthermore, medical experience regarding prolonged somatic support is limited and can be considered experimental therapy. This article explores these issues by considering the concept of brain death and how it relates to somatic death. The current limits of fetal viability are then discussed. The complex ethical issues and the important variations in the legal context worldwide are considered. Finally, the likelihood of successfully sustaining maternal somatic function for prolonged periods and the medical and obstetric issues that are likely to arise are examined.

__________________________________________________________

Journal of transplant coordination

J Transpl Coord. 1997 Sep;7(3):103-5.

dead Organ recovery following childbirth by a brain-mother: a case report.

Lewis DD, Vidovich RR.

Ohio Valley LifeCenter, Cincinnati, USA.

Little information is available in the medical and nursing literature concerning organ recovery from brain-dead, pregnant individuals. Many healthcare professionals might rule out such patients as potential donors, especially if childbirth is a possibility. This article presents an actual case study in which the birth of a healthy infant and recovery of organs from the mother were successful. It also reviews the available literature and discusses factors related to organ placement.

__________________________________________________________

Journal of Obstetrics and Gynaecology

Obstet Gynecol. 1989 Sep;74(3 Pt 2):434-7.

Maternal brain death and prolonged fetal survival.

Bernstein IM, Watson M, Simmons GM, Catalano PM, Davis G, Collins R.

Department of Obstetrics and Gynecology, Medical Center Hospital, Vermont, Burlington.

A 30-year-old woman suffered massive brain injuries after a motor vehicle accident at 15 weeks' gestation. The patient was diagnosed as brain-dead on her tenth hospital day. She was supported with intensive care for 107 days after this diagnosis, and a normal 1555-g male infant was delivered at approximately 32 weeks' gestation by repeat cesarean section. The child is developing normally at 11 months of age. This represents the longest reported case of prolongation of pregnancy after brain death

__________________________________________________________

Minerva Anestesiologica

A Journal on Anesthesiology, Resuscitation, Analgesia and Intensive Care

Minerva Anestesiol. 1992 Nov;58(11):1247-52.

Brain death and prolonged fetal survival
[Article in Italian]

Antonini C, Alleva S, Campailla MT, Pelosi G, Valle E, Verrua M, Zamponi E, Blanda A, Gambaro C.

Facoltà di Medicina e Chirurgia, Università degli Studi di Torino.

The Authors presents in detail a case of a 25-year-old primigravida that had fatal intracranial bleeding at the beginning of the 15th week of gestation, whose vital function are sustained for 49 days. Despite the insuccess to bring the pregnancy to a gestational period favorable to induce the delivery, they analyse the problems connected to the maternal maintenance and to the fetal growth.