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Maternal Brain Death During Pregnancy

Medical and Ethical Issues


David R. Field, MD; Elena A. Gates, MD; Robert K. Creasy, MD;
Albert R. Jonsen, PhD; Russell K. Laros, Jr, MD

We present in detail a case of a 27-year-old primigravida who was maintained in viving infant 63 days after the diagnosis
a brain-dead state for nine weeks. An apparently normal and healthy male infant of brain death was made.
weighing 1440 g was delivered. The newborn did well and was found to be REPORT OF A CASE
growing and developing normally at 18 months of age. Although the technical On Jan 25,1983, a previously healthy
aspects of prolonged life support are demanding and the economic costs are 27-year-old grávida 1, para 0 woman
very high ($217 784), there are ample ethical arguments justifying the separa- presented to her local hospital at 22
tion of brain death and somatic death and the maintenance of the brain-dead weeks' gestation with a five-day history
mother so that her unborn fetus can develop and mature. of worsening headaches followed by
(JAMA 1988;260:816-822) several hours of vomiting and disorien¬
tation. Results of physical examination
were consistent with a 22-week gesta¬
BRAIN death, the unequivocal and ir¬ is generally considered unethical to tion and were otherwise unremarkable;
reversible loss of total brain function, is squander costly medical resources by normal vital signs and no focal neuro¬
a concept used to determine when death continuing to support vital functions logic deficits were noted. Results of a
has occurred in cases in which life-sup¬ using artificial means. lumbar puncture were normal except
port equipment obscures the conven¬ Maternal brain death during preg¬ for a slightly elevated opening pressure
tional cardiopulmonary criteria of nancy is one instance in which prolonged of 20 cm of water and the presence of
death.1,2 This concept has gained wide maintenance of the mother's vital func¬ four segmented neutrophils per cubic
acceptance in the medical and legal com¬ tions might be justified for the sake millimeter of cerebrospinal fluid. Four
munities, and most states have passed of the fetus. Tb our knowledge, Dillon hours after presentation, the patient
brain-death statutes specifying the cri¬ et al3 reported the first case in which had a generalized seizure and a respira¬
teria needed to make the diagnosis of prolonged support of a brain-dead tory arrest.
brain death and equating that diagnosis mother resulted in the birth of an infant After cardiopulmonary resuscitation,
with the pronouncement of death.2 who survived. Though they suggested ventilatory support was continued in
Despite meticulous supportive care, guidelines for the treatment of these the intensive care unit, where examina¬
brain death is usually followed by car¬ patients, the decision of whether to con¬ tion revealed no response to painful
diovascular collapse within a few days tinue maximum supportive care in these stimuli, fixed and dilated pupils, papil-
and, once such a diagnosis is made, it rare and tragic cases remains a contro¬ ledema, and absent doll's eye move¬
versial one.4 ments. A computed tomographic scan of
From the Department of Obstetrics, Gynecology, and
Reproductive Sciences (Drs Field, Gates, Creasy, and Fundamental to this controversy are the head showed marked dilatation of
Laros) and the Division of Ethics in Medicine (Dr Jon- ethical and economic issues as well as the lateral and third ventricles with a
sen), University of California, San Francisco. Dr Field is unanswered questions concerning the mass obstructing the fourth ventricle.
now with the Department of Obstetrics and Gynecolo-
physiologic consequences to both the A ventriculostomy was placed and
gy, Naval Hospital, Oakland, Calif. Dr Creasy is now
with the Department of Obstetrics and Gynecology, mother and fetus of prolonged support revealed clear cerebrospinal fluid that
University of Texas, Houston. Dr Jonsen is now with the of the organ systems most prone to fail¬ had an opening pressure of 50 cm of
Department of Medical Ethics, University of Washing- water. Dexamethasone sodium phos¬
ton, Seattle. ure after brain death. We will examine
Reprint requests to Department of Obstetrics, Gyne- these issues and questions using as a phate and mannitol were given, but the
cology, and Reproductive Sciences, M-1485, Universi- framework for our discussion the case electroencephalogram was again iso-
ty of California, San Francisco, CA 94143-0132 (Dr
Laros). report of a woman who delivered a sur- electric two days later. There was no

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change in the patient's condition, and a hours for two doses) were given, and even with the most intensive care, is
diagnosis of brain death was made at nonstress tests were performed twice a said to never last for more than 14 days
that time, using the Harvard criteria.5 week. after brain death. "
During this period the fetal heart rate On the 28th day of hospitalization, Somatic survival after brain death is
pattern remained normal. In accor¬ enterococcal bacteremia developed; this not a natural event. It represents the
dance with the strongly expressed was initially treated with ampicillin so¬ culmination of impressive advances in
wishes of the father, a decision was dium and gentamicin sulfate. This regi¬ medical knowledge, skills, and technol¬
made to provide cardiorespiratory sup¬ men was changed to piperacillin sodium ogy applied to life-support strategies in
port to the mother in an attempt to after the sensitivity results were re¬ critical care medicine. The use of such
maintain the fetus in utero until it ported, and the bacteremia resolved. A resources on a person already declared
reached a viable gestational age. Staphylococcus aureus bacteremia de¬ dead, however, has previously been
Bilateral patchy pulmonary infil¬ veloped on the 58th day of hospitaliza¬ advocated only for relatively short peri¬
trates consistent with the adult respira¬ tion and was treated with nafcillin sodi¬ ods to preserve viable organs for trans¬
tory distress syndrome (ARDS) soon um. During the course of that plantation. 12 " The longer-term sequelae
appeared roentgenographically. Diabe¬ treatment, a repeated sonogram of such support are unknown. Never¬
tes insipidus developed, and injections showed no evidence of fetal growth over theless, several reviews have examined
of vasopressin were required to control the previous two weeks. Because of the the fate of patients receiving maximum
the massive diuresis and hypernatre- suspected intrauterine fetal growth re¬ supportive care who retrospectively fit
mia. Trimethoprim and sulfamethoxa- tardation and recurrent septicemia, a the criteria of brain death. These sur¬
zole were given to treat a Klebsiella decision was made to deliver the fetus veys conclude that cardiopulmonary
urinary tract infection. Total parenteral by cesarean section on the 63rd hospital respiratory function can, on average, be
nutrition (TPN) was begun, providing day at 31 weeks' gestation. A 1440-g maintained for only a few days after
6300 kJ/d, and 2 U of packed red blood male infant with Apgar scores of 8 at one brain death.7,11,1616 In their series of over
cells was transfused. The patient was and five minutes was delivered on 1200 brain-dead patients, Jennett and
transferred to Moffitt Hospital at the March 29, 1983. Maternal ventilatory Hessett" were unable to find a single
University of California at San Fran¬ support was discontinued postopera- case ofbrain death with cardiac survival
cisco (UCSF) on the 14th day of her tively, and cardiac activity ceased beyond 14 days, but cases of more pro¬
hospitalization, at 24 weeks' gestation. shortly thereafter. The autopsy re¬ longed somatic survival have subse¬
On admission at UCSF, the patient vealed holonecrosis of the brain that quently been reported.3,17,18 It is possible
hadatemperatureof38.9°C, and results obliterated the histologie findings and that this lack of prolonged somatic sur¬
of the neurologic examination were con¬ prevented a tissue diagnosis. The vival is due as much to the prognostic
sistent with the diagnosis of brain autopsy also showed bilateral broncho- futility of maintaining cardiorespira-
death. The uterine fundus measured 23 pneumonia, congestive hepatomegaly tory support in a brain-dead patient as it
cm, and a sonogram revealed a vigorous with mild fatty change, and bilateral is to any inherent technical difficulty in
fetus with anthropométrie criteria con¬ pyelonephritis. maintaining such support.
sistent with 24 weeks' gestation. Full The infant was cared for in the neona¬ Brain death complicating pregnancy
ventilatory support was continued and tal intensive care unit, where mild res¬ is one instance in which prolonged
modulated on the basis of frequent arte¬ piratory distress syndrome developed. maternal cardiorespiratory support
rial blood gas determinations. Maxi¬ However, he generally did well and was might be justified for the sake of the
mum effort was directed at treating the transferred to a hospital nearer his fetus. As far as we know, ours is the
severe hypotension, temperature fluc¬ home at 3 weeks of age. On follow-up second reported case in which this sup¬
tuations, diabetes insipidus, hypothy- examination at 18 months of age, he was port was undertaken with successful
roidism, and cortisol deficiency that found to be growing and developing neonatal results and represents by far
were thought to be the result of loss of normally. the longest time a mother has received
the autoregulatory function of the such support. Dillon et al3 reported two
brain. The hypotension responded to COMMENT cases of pregnancy complicated by
plasma expanders and a combination of Brain death can be diagnosed using maternal brain death. In their first case
vasopressors. Heating and cooling blan¬ several sets of guidelines'2,M that have the mother was at 18 weeks' gestation,
kets stabilized the patient's tempera¬ in common the documentation of abso¬ and although the procedures for docu¬
ture. A vasopressin infusion alleviated lute and incontrovertible cessation of menting brain death were not fully car¬
the signs of diabetes insipidus, and both total brain function. Brain death is thus ried out, the authors decided to stop life
thyroxine and cortisol were adminis¬ clearly delineated from other states of support. In their second case, brain
tered in normal replacement doses. profoundly impaired brain function in death was diagnosed at 25 weeks' gesta¬
A trial of nasogastric feedings failed. which supportive care to preserve vital tion, and the maternal vital functions
Therefore, TPN was restarted and functions is also required. The most were maintained for seven days, until
maintained at a rate that supplied 9500 severe of these other conditions, vari¬ maternal hypotension associated with
kJ/d. Hyperglycemia developed and ously called cerebral death,'1 persistent variable fetal heart rate decelerations
was treated with a continuous insulin vegetative state,9 or the apallic syn¬ prompted the delivery of a surviving
infusion. Nutritional assessments re¬ drome,10 is characterized by the func¬ 930-g infant.
vealed that the patient had a positive tional loss of the cerebral hemispheres Dillon et al3 suggested a management
nitrogen balance, and the serum albu¬ with retention of at least some brain- plan for these patients based on the neo¬
min concentration rose from 362 to 449 stem function. This residual brain-stem natal survival statistics in their nurs¬
u.mol/L during the hospitalization. function allows patients to sometimes ery,19 economic considerations, and the
Fetal heart tones were monitored every survive for years. Brain death, in which lack of evidence that support could pro¬
shift, and serial obstetric sonograms the entire brain is destroyed as surely as long somatic life for more than a couple
were performed. After 26 weeks of ges¬ if decapitation had occurred, is dis¬ of weeks after brain death. They recom¬
tation, weekly betamethasone sodium tinctly different from cerebral death. mended that when maternal brain death
phosphate injections (12 mg every 12 The preservation of vital functions, occurs before 24 weeks' gestation, no

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Suggested Measures for Physiologic Support in directed at maintaining an optimum tory renal bicarbonate loss resulting in a
Pregnancy Complicated by Maternal Brain Death environment for the developing fetus. serum level of 18 to 21 mmol/L (normal

Mechanical ventilation with ventilator with volume


Our discussion of medical management range, 24 to 30 mmol/L), with the pH
preset. will focus on the ramifications for the maintained in the normal range of 7.40
Start with a tidal volume of 10 to 15 mlVkg, fetus of supporting those systems that to 7.45. This compensatory respiratory
respirations of 10/min to 12/min, and a fraction fail after maternal brain death. After alkalosis approximates that seen in nor¬
of inspired oxygen (Fio2) of 1.0. Make
subsequent ventilator adjustments on the basis addressing the unique implications that mal pregnancy.
of arterial blood gas determinations. medical support of a brain-dead mother In some patients who suffer brain
Decrease the Fio2 to <0.6 while maintaining the
arterial oxygen saturation at 90%. might have for the fetus, we will exam¬ death because of severe head trauma,
Adjust the respiratory rate to maintain the arterial
carbon dioxide tension at 28 to 32 mm Hg.
ine the ethical and economic issues neurogenic pulmonary edema quickly
If the arterial oxygen tension is <60 mm Hg while involved in such support. develops, possibly due to a centrally
the F102 is >0.5, add positive end-expiratory mediated, massive, sympathetic dis¬
pressure by starting at 3 to 5 cm of water and
titrating upward until the oxygénation improves
Respiratory Support charge producing transient systemic
or the cardiac output declines. The respiratory center, located in the and pulmonary vascular hypertension.23
Vasopressors to treat fluid-resistant hypotension.
Start with a continuous intravenous infusion of brain stem, has two main parts: the Our patient had a clinical picture consis¬
dopamine (2 to 5 \ig kg min), and titrate upward medullary center, which is responsible tent with the diagnosis of ARDS, but
until a mean arterial pressure of 80 to 110 mm Hg for the initiation and maintenance of whether this ARDS was truly neuro¬
is reached.
If the desired mean arterial pressure is not achieved spontaneous respiration; and the pneu- genic or secondary to hypoxia occurring
at dopamine infusion rates of 12 to 15 |j.g/kg/min,
add dobutamine at a continuous infusion rate of
motaxic center, in the pons, which helps during her initial resuscitation is a
2.5 to 15.0 iig/kg/min. coordinate cyclic respirations. Since moot point. The use of positive end-
Warming or cooling blankets to treat temperature both of these areas cease to function expiratory pressure, beginning at 5 cm
lability. with brain death, cessation of spontane¬ of water and titrating upward until the
Nutritional support using enterai tube feedings or total
parenteral nutrition. ous respirations is a prerequisite for the respiratory measures improve or until
Maintain daily energy intake of 126 to 147 kJ/kg
diagnosis.11 Thus, brain-dead patients the cardiac output declines, is bene¬
for ideal body weight. ficial in this situation. The ventilator-
Treat hyperglycemia with insulin. must always receive mechanical venti-
Treat endocrine abnormalities with replacement
hormones.
latory support. The general principles perfusion relationships improve with
Vasopressin. involved in the ventilator adjustments positive end-expiratory pressure, and
Thyroxine. are the same as for any patient with the concentration of inspired oxygen re¬
Corticosteroids.
Aggressive surveillance for and treatment of respiratory failure. During pregnancy, quired to maintain the arterial satura¬
infections. however, there are some differences in tion above 90% can be reduced.24 The
Heparin prophylaxis. the respiratory physiologic characteris¬ effects of prolonged high levels of the
tics that affect ventilatory care and fraction of inspired oxygen on the fetus
deserve mention (Table). are unknown, but evidence suggests

Pregnancy is associated with a cen¬ that a fraction of inspired oxygen of


tral, hormonally mediated increase in 0.5 can be administered indefinitely
extraordinary measures should be ventilation leading to a chronic respira¬ without adverse effects on the mother
undertaken for either the mother or the tory alkalosis. Examination of the diffu¬ or, presumably, the fetus.26
fetus; when it occurs after 28 weeks' sion dynamics taking place across the
Cardiovascular Support
gestation, delivery by cesarean section placenta reveals that this physiologic
should be done as soon as possible; and maternal hypocarbia establishes a diffu¬ The nucleus of the vagus nerve is
when brain death occurs between 24 and sion gradient that facilitates the elimi¬ located in the medulla, and in the case of
27 weeks' gestation, life-support mea¬ nation of carbon dioxide from the fetus. brain death there is a subsequent com¬
sures should be started, with immediate Because of this, maternal carbon diox¬ plete cessation of vagal activity. On
delivery reserved for instances of fetal ide tensions should be maintained in the the other hand, the nuclei that operate
distress or significant deterioration of normal pregnancy range of 28 to 32 mm the sympathetic nervous system are
the mother's condition. In contrast to Hg rather than the range of 38 to 45 located in the spinal cord, and they sur¬
these recommendations, our case dem¬ mm Hg seen in normal nonpregnant vive. Thus, cardiac activity after brain
onstrates that stable somatic survival patients.20 Using controlled hyperventi- death seems to be determined by the
can sometimes be maintained for lation to maintain a degree of hypocar¬ sympathetic system alone, and the exis¬
months, and in these instances the preg¬ bia has long been advocated as a stan¬ tence of spinal reflex circuits without
nancy might safely be allowed to contin¬ dard measure of brain-oriented life any cerebral influence has been demon¬
ue past 28 weeks of gestation. support of comatose patients because it strated in these patients.26 However,
The medical management of our decreases intracranial pressure, coun¬ tachycardia was reported in less than
patient required the cooperative team¬ teracts cerebral acidosis, and improves half of the brain-dead patients whose
work of a host of health care profession¬ intracerebral blood flow distribution.21 electrocardiograms were analyzed, and
als from a variety of specialties. None of Since brain function is already irrevers¬ then only during the initial phase of
these specialists had experience with ibly lost in brain death, moderate con¬ brain death.16 Subsequent slowing ofthe
similar cases, and there was a paucity of trolled hyperventilation is advocated in heart rate was noted in all of these
information in the literature regarding this instance only to enhance the intra¬ patients, suggesting that additional
the complications to be expected from uterine milieu. However, hyperventila¬ influences, such as hypothermia or sub-
such prolonged somatic survival. As we tion to decrease the maternal arterial clinical myocardial hypoxia, were coun¬
faced these problems and attempted to carbon dioxide tension to levels below teracting the stimulatory effect of the
evaluate the impact of our therapeutic 30 mm Hg for prolonged periods has sympathetic nervous system. It is pos¬
regimens on the fetus, we extrapolated been shown in lambs to cause marked sibly because of these influences that
from knowledge gained in the manage¬ reductions in placental perfusion,22 and cardiac arrest generally occurs within a
ment of isolated organ system failure this degree of hypocarbia should be few days of brain death.7,11,16,16 However,
avoided. If a small degree of hypocarbia our case and others17,18 suggest that with
during pregnancy. That knowledge was meticulous supportive care, a "beating
incorporated into a coherent plan is maintained, there will be a compensa-

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heart cadaver" can be maintained for ct-adrenergic activity. Like dopamine, tion of the loss of thermorégulation in
months. it should be given by intravenous infu¬ brain-dead patients with prolonged
Experience with cardiac and renal sion, and it also appears to have a bipha- somatic survival unless specific steps
transplant donors has demonstrated sic effect on peripheral blood vessels at are taken to prevent it.
that hypotension, requiring treatment low dosages (ie, 5 p,g/kg/min), causing Prolonged maternal hypothermia is
with pressor agents, develops in the some increase in tone, while higher dos¬ not a situation often encountered in clin¬
vast majority of brain-dead patients.12,13 ages (ie, 30 p,g/kg/min) induce muscular ical practice, and its effect on the fetus is
The problem of hypotension is particu¬ relaxation.29 Dobutamine's ability to unknown. The fetus normally depends
larly important in pregnant women improve ventricular contractility with¬ on passive thermorégulation by heat
because the uterine vasculature is not out markedly increasing the heart rate exchange with the mother's blood at the
an autoregulated system, and maternal or dilating resistance vessels suggests intervillus space. Our knowledge con¬
hypotension severely decreases the that in low doses it is a useful adjunctive cerning the degree of active thermorég¬
uteroplacental blood flow.27 The devel¬ measure for the control of hypotension ulation in the fetus is limited. Gluckman
opment of diabetes insipidus, with its in this setting. et al33 showed that the fetal lamb re¬
attendant intravascular volume con¬ Endocrine problems caused by the sponds to cooling with shivering and
traction, can complicate the differentia¬ development of panhypopituitarism that cooling cutaneous thermoreceptors
tion between hypovolemia and the loss contributed to the hypotension in our on the fetus can alter fetal electrocorti-
of central autoregulation as the cause of patient. The most prominent of these cal activity and breathing patterns.
the hypotension. We therefore recom¬ was diabetes insipidus, a condition that This suggests that cooling is a deleteri¬
mend the determination of central develops in the majority of brain-dead ous state, since fetal energy is directed
venous pressures as an important aid in patients who are kept alive for more away from the primary process of
the management of the fluid status. If than a few days.30 In this condition, mas¬ growth and development during hypo¬
pulmonary edema develops, we strong¬ sive polyuria and the resultant hyperna- thermia. We therefore recommend vigi¬
ly recommend that a Swan-Ganz cathe¬ tremia can generally be controlled by lance in maintaining a normal maternal
ter be used to differentiate cardiogenic giving vasopressin either intramuscu¬ temperature by using warming blankets
pulmonary edema from ARDS and to larly or by intravenous infusion and by andwarm,inspired,humidified air.
guide fluid therapy. Once fluid- using pulmonary artery and wedge Though it was rarely seen during pro¬
resistant hypotension is documented, pressures to guide fluid replacement.12 longed support after brain death, our
the hypotension should be aggressively Hypotension is also associated with sec¬ patient also had periods of hyperther-
treated pharmacologically. The use of ondary adrenocortical insufficiency, mia. After an infectious process had
vasopressors requires that an arterial which should be anticipated in these pa¬ been ruled out, we believed that this
line be inserted to continuously monitor tients and treated with replacement hyperthermia was a further reflection
blood pressure. doses of corticosteroids if it is found. of poikilothermia, since our patient had
Because of its unique pharmacologie Finally, the mother should always be an autonomous internal heat generator,
properties, low-dose dopamine hydro- kept in a lateral or lateral tilting position the metabolically active fetus. The dele¬
chloride was chosen as the initial agent to avoid the detrimental supine hypo- terious effects of prolonged maternal
for treating the hypotension seen in our tensive effects of uterine aortocaval hyperthermia on the fetus have been
patient. In low doses, dopamine has a compression. The importance of this is suggested by previous studies,34,36 and
weak betamimetic effect on the heart, emphasized by a case report ofmaternal we recommend the use of cooling blan¬
increasing contractility and the heart survival after "postmortem" cesarean kets as needed to maintain the maternal
rate without increasing myocardial ox¬ section emptied the uterus and allowed core temperature in the normal range.
ygen consumption disproportionately. effective blood flow to return.31 Hypo¬
It also stimulates dopaminergic recep¬ tension was effectively treated in our Nutritional Support
tors in the renal, mesenteric, and coro¬ patient by the use of fluid resuscita¬ Our patient had no intrinsic gastroin¬
nary vasculature, causing vasodilata¬ tion, invasive hemodynamic monitor¬ testinal pathologic findings and was in a
tion. Unlike pure beta-stimulants, ing, aggressive pharmacologie support, state of good nutritional balance before
dopamine causes vasoconstriction of hormonal replacement therapy, and her intracranial catastrophe. Since
skeletal muscle, so while its net effect is optimal maternal positioning, and the bowel sounds were present when she
to elevate blood pressure, the renal and mean arterial pressures were main¬ was admitted to our unit, enterai tube
splanchnic blood flows are preserved.28 tained in a range that is believed feedings were begun with the aim of
These actions of dopamine, however, to ensure optimal uteroplacental providing 10100 kJ/d. Sampson and
are dose dependent. In dosages exceed¬ perfusion. Peterson36 had previously reported the
ing 15 to 20 |xg/kg/min, the principal case of a pregnant patient in a posttrau-
effect is on alpha-receptors, resulting in Temperature Liability matic vegetative state who was given
generalized vasoconstriction and de¬ Because of the loss of the hypothal- nasogastric feedings for seven months
creased uteroplacental perfusion. Do¬ amic thermoregulatory mechanism, the before she delivered an adequately
pamine, therefore, needs to be adminis¬ normal diurnal fluctuations of body tem¬ grown infant after 33 weeks of gesta¬
tered by continuous intravenous perature are characteristically absent tion. Smith et al87 also reported their
infusion starting at 2 to 5 p-g/kg/min and in brain death, and the body tempera¬ successful experience with the use of
titrating upward to achieve the desired ture tends to follow that of the environ¬ long-term enterai hyperalimentation in
hemodynamic effect. If that effect is ment. Jorgensen32 found that this poiki- two pregnant diabetics with hypereme-
not seen by the time infusion rates ap¬ lothermia was a constant finding when sis gravidarum. In our patient, how¬
proach 12 to 15 p,g/kg/min, we recom¬ somatic survival was maintained for ever, the plan to provide enterai nutri¬
mend adding dobutamine hydrochloride more than 24 hours. Although a minor¬ tion through a nasogastric tube was
(Table). ity of his patients demonstrated initial thwarted due to the poor motility of her
Dobutamine is a sympathomimetic hyperthermia, all had final asystole gastrointestinal tract. This poor motil¬
amine that has major cardiac ß^adren- within 24 hours. Thus, hypothermia ity was reflected by large gastric residu¬
ergic activity along with minor ßz- and seems to be the predominant manifesta- als and reflux régurgitation even

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though the feeding tube was passed patient's panhypopituitarism was evi¬ the fetal benefits, measured in the
through the pylorus into the duodenum. denced by secondary hypothyroidism chance for good-quality survival, must
Therefore, TPN was initiated through a that required physiologic replacement be weighed against the risks to the
subclavian vein. doses of levothyroxine. Perfusion of the mother of operative delivery. Since a
There have been a number of reports kidneys was maintained by the ag¬ postmortem cesarean section entailed
of the use of TPN during pregnancies gressive treatment of hypotension, no additional risk to the mother, at 26
complicated by a variety of disor¬ and renal function remained nor¬ weeks' gestation we were prepared to
ders.3"2 The use of TPN during preg¬ mal throughout the patient's course. intervene for the sake of the fetus if
nancy has been shown to be beneficial Because of the increased risk of throm¬ there was any significant deterioration
according to the criteria of maintenance bosis associated with prolonged bed in the mother's physiologic meausures.
of a positive nitrogen balance, maternal rest in the absence of any muscle tone, As others have recommended, delivery
weight gain, and normal fetal growth as prophylactic heparin sodium was given was to be by classic cesarean section to
reflected by sonographic measurements subcutaneously in doses of 5000 U every provide the most expeditious and least
and birth weight.41 However, there are 12 hours. traumatic birth for the fetus.46 A surgi¬
major risks associated with TPN, Intensive infection-control precau¬ cal kit was kept at the patient's bed¬
including hyperglycemia, sepsis, and tions were an integral part of the side, and standing orders were made
complications resulting from placement patient's care. She remained continu¬ to increase the mother's fraction of
of a central line. Hyperglycemia is a ously at high risk for septicemia because inspired oxygen to 100% at the first
common complication in any patient she was receiving mechanical ventila- sign of acute maternal deterioration.
receiving TPN, but it seems especially tory support, was receiving TPN, and Informed consent was obtained from
likely to occur when TPN is given dur¬ had a Swan-Ganz catheter as well as a the father, who was in complete agree¬
ing pregnancy, a condition that is itself urinary catheter and an arterial line in ment with this plan.
inherently diabetogenic. If it is not con¬ place. Since she had lost the ability to Our primary means of providing the
trolled, maternal hyperglycemia stimu¬ demonstrate many of the signs of infec¬ most beneficial intrauterine environ¬
lates fetal insulin production and results tion because of her poikilothermy and ment for the fetus was to ensure that the
in increased fetal fat storage. A syn¬ hypotensive state, infection surveil¬ maternal physiologic measures were as
drome similar to that seen in the infants lance consisted of maintaining a con¬ close to normal as possible. However, it
of diabetic mothers could then develop. stant high index of suspicion and utiliz¬ would be naive to presume that we
Therefore, when maternal hyperglyce¬ ing frequent blood, urine, and sputum could, even with our sophisticated sup¬
mia appears during TPN, we recom¬ cultures as a screen for pathogenic or¬ portive and monitoring techniques,
mend aggressive treatment with con¬ ganisms. Bladder and respiratory colo¬ maintain an intrauterine environment
tinuous insulin infusion to maintain nizations were aggressively treated. as conducive to fetal growth and devel¬
euglycemia. Great care was exercised in maintaining opment as the one present in an other¬
We calculated the patient's energy strict asepsis in handling the intrave¬ wise healthy grávida. Because of
needs to be 9500 kJ/d based on the rec¬ nous lines, and these lines were changed this, at 27 weeks of gestation, we insti¬
ommendation of 130 to 150 kJ/kg/d for regularly. Finally, the importance of tuted the same strategy of aggressive
ideal body weight.43 This daily energy expert, dedicated nursing care in the fetal surveillance that we would use in
was given in the form of a fat emulsion overall management of this state cannot any extremely high-risk pregnancy.
(2100 kJ), 100 g of protein (1700 kJ), and be overemphasized. Although the usefulness of antepartum
a 20% dextrose solution that supplied fetal heart rate monitoring at that ges¬
the rest of the calculated energy Obstetric Strategies tational age has been questioned, there
requirement. Heller,44 studying TPN in Our premise was that by artificially is evidence that it is predictable
pregnant rats receiving 50% of their supporting the maternal vital functions between 27 and 30 weeks' gestation.47
energy intake as fat, concluded that we could maintain an intrauterine envi¬ We therefore used a regimen of
there is a risk of fatty infiltration of the ronment that was at least adequate to nonstress tests twice weekly with oxy-
placenta if parenteral fat emulsions are allow the fetus to develop in utero until tocin challenge tests reserved for use if
used during pregnancy. However, this it had reached a gestational age compat¬ the nonstress test results were suspi¬
complication has not been seen when ible with a chance of extrauterine sur¬ cious or nonreactive. Ultrasound ex¬
commercial fat emulsions are used clini¬ vival. At UCSF, 28 weeks' gestation is aminations were performed every two
cally to supply up to 20% of the daily associated with a greater than 80% weeks to document adequate fetal
energy requirements during preg¬ chance of neonatal survival. The attain¬ growth. It was, finally, the lack of
nancy. We therefore recommend that ment of this gestational age was our sonographically detected fetal growth
moderate amounts of fat emulsion be initial goal. However, the care of a 28- during the last two weeks of the preg¬
added to the TPN solutions used during week-old neonate in the intensive care nancy, coupled with recurrent maternal
pregnancy, not only to prevent mater¬ nursery is itself a costly and precarious sepsis, that prompted us to deliver the
nal essential fatty acid deficiency but proposition that becomes less so with infant.
also to provide linoleic acid for the fetus. each subsequent week of gestation.46 Ethical Considerations
When this regimen was used, our We therefore decided to prolong mater¬
patient's nutritional status was judged nal life support until 34 weeks of gesta¬ In the last two decades, the tradi¬
to be adequate on the basis of positive tion as long as there were no indications tional cardiopulmonary signs that indi¬
nitrogen balance tests, a 16-kg weight of deterioration in the condition of the cated death have been supplemented by
gain, and a rise in her serum albumin mother or the fetus. This strategy is at signs of the loss of brain activity. This
concentration to levels normal for odds with the guidelines proposed by change was made necessary by the
pregnancy. Dillon et al.3 introduction of techniques of respira¬
Miscellaneous Medical Problems
It is always difficult for the obstetri¬ tory support that could mask the tradi¬
cian to determine the gestational age at tional signs of the onset of death. Also,
In addition to diabetes insipidus and which it becomes reasonable to inter¬ the introduction of renal and cardiac
secondary adrenal insufficiency, the vene for the sake of the fetus. Usually, transplantation stimulated interest in a

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means of determining death that could fetus violates the pregnant woman's premature delivery with attendant
allow organs to be removed from a still autonomy. Resort to the courts is almost
. .

morbidity and mortality, and the risk of


oxygenated but legally dead body. Cri¬ never justified. iatrogenic damage. These should be
teria for this new definition of death The substantive issues in this conflict weighed against the expected benefit of
were first issued by a committee of the between maternal and fetal "rights" do delivery of a viable and healthy infant.
Harvard Medical School, Boston.6 In not seem relevant to the case ofmainte¬ We judge that it is ethically acceptable
1981, the President's Commission for nance of a maternal cadaver to incubate to strive to
rescue the fetus if there is a
the Study of Ethical Problems in Medi¬ a fetus to viability. Maternal autonomy, reasonable chance it will reach fetal
cine and Biomédical and Behavioral in the sense of the active preferences of maturity.
Research48 recommended a uniform the mother, ceases with her death. Her Once maternal support has been
statute that has now been adopted by actual permission or refusal is irrele¬ elected, ongoing intrauterine fetal
most American jurisdictions: vant because it is impossible to obtain. assessment may suggest a shift in the
An individual who has sustained either: (1) Although legal and ethical tradition balance of risk and benefit, leading to a
irreversible cessation of circulatory and res¬ does respect the previously expressed decision to deliver before fetal maturity
piratory function or (2) irreversible cessation wishes of the decedent with regard to has been achieved. For this reason, it is
of all functions of the entire brain, including inheritance, disposition of remains, and less clear whether the anticipated risks
the brain stem, is dead. A determination of transplantation,60,61 this tradition would would be justified in the case of a fetus
death must be made in accordance with not seem to override in importance the that is clearly quite remote from viabil¬
accepted medical standards. obligation to save an endangered fetal ity. In such a case, delivery before
It is now possible to separate physi¬ life. Even a maternal refusal expressed maturity would seem likely. Certain
cally and temporally the death of the before death does not, in itself, carry death in utero or at immediate delivery
entire organism and the "death" of the weight against the possibility of fetal is exchanged for the potential risk of
brain.49 A delay of extubation in a person survival. The mother is not harmed; no long-term damage due to premature
judged to be dead by brain criteria can right of hers is violated, and great good delivery or to the extraordinary care
be justified for compassionate reasons, can be done for another. Thus, this case provided the mother's body. Further
such as the expected arrival of relatives, seems to present a straightforward experience with cases such as the pre¬
for the perfusion of organs to be trans¬ instance of the medical rescue of the sent one may provide evidence justify¬
planted, and for certain research pur¬ fetus from death. ing intervention earlier in gestation.
poses. Recently, another situation has A long tradition of fetal rescue exists Risks and benefits to the family and to
arisen because ofthe technical advances in Western society. Asklepios was "cut society should also be considered,
reported in this article, namely, the out alive from the womb of his dead though they are unlikely to be decisive.
ability to support the vital activity of a mother by Apollo. "62 During the reign of Cost is a major concern, both to the
pregnant woman who is dead by brain King Numa Pompilius of Rome in the individual family and to society as a
criteria to allow her fetus to mature seventh century BC, the Lex Regia was whole. In the present case, costs for
until a safe delivery is possible. established, mandating the abdominal maternal care totaled $183 081, and the
During the course of prenatal care, an delivery of a term fetus in the event of cost of the neonatal care was $34 703.
obstetrician's primary obligation to the the death of its mother. Six hundred Maternal somatic support may be cost-
pregnant patient is to support her bio¬ years later, during the time of the efficient if weeks of neonatal intensive
logic and mental well-being both for her Roman emperors, this became known care are prevented by the less costly
sake and to promote the life and health as the Lex Cesárea, the origination of support of a cadaver. In the case of the
of her fetus. Increasingly, the fetus is the term cesarean delivery.62 The dis¬ clearly previable fetus, however, such a
considered a patient as well, by virtue of cussion of postmortem cesarean deliv¬ cost analysis would not provide justifi¬
the fact that it is a developing human ery has been continued in the medical cation. Societal risk also arises in the
whose treatable conditions can be literature.63 Currently available tech¬ possibility that a precedent may be set
affected by specific medical interven¬ nology has made postmortem somatic requiring maternal somatic support in
tions. For the individual physician, the support of a mother possible to effect all cases, regardless of the individual
fetus becomes a potential patient when the "rescue" of her very premature considerations that have been outlined.
its mother presents for prenatal care. fetus. Could the existence of this tech¬ Were this to occur, the best interests of
In recent years, a small medical, nology lead to the requirement that it be the individual fetus might no longer be
legal, and ethical literature has applied in all cases of maternal death? the basis for decisions about maternal
appeared concerning the issues raised In traditional ethics, the obligation to support.
by the maternal refusal of a procedure rescue an endangered life is serious but It is important that the person best
or regimen recommended for the wel¬ conditional. An evaluation of the risks able to speak for the interests of the
fare of her fetus.60"64 A series of judi¬ and benefits attendant on the effort to fetus be in a position to make necessary
cial decisions granting permission for rescue is required. Efforts to rescue decisions about maternal somatic sup¬
such interventions despite maternal re¬ should be carried out unless they expose port. When decisions are required in the
fusal has stimulated interest in this the rescuer to serious risk. In the case of setting of neonatal intensive care, par¬
question.66 Despite the judicial readi¬ the fetus after the death of its mother, ents are given fairly broad limits as to
ness to intervene on behalf of the fetus, however, the obligation to rescue would the treatment they wish administered
most authors argue that maternal be conditioned primarily on risks to the to their children, because it is generally
autonomy should have ethical and legal rescued. The mother is now beyond ben¬ assumed that they have their children's
priority in all, or almost all, circum¬ efit or harm. Decisions should be based best interests in mind.64 Furthermore,
stances.6"8 This statement of the on the principles of nonmaleficence and the next of kin traditionally has the
Committee on Ethics of the American beneficence toward the fetus, or, more authority to make decisions about the
College of Obstetricians and Gynecolo¬ properly, toward the child who will be disposition of the body after death. This
gists69 reflects this viewpoint: born. These principles should be applied has support in the American legal tradi¬
The use of judicial authority to implement by assessing the risk of death in utero— tion through the Uniform Anatomical
treatment regimens in order to protect the less a risk than a certainty, the risk of Gift Act.60 In the case presented here,

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the husband of the deceased is also the propriate to respect the wishes of the heart cadaver" for purposes of nurtur¬
father of the fetus and, thus, is the father in decisions about somatic sup¬ ing the fetus have been examined. The
appropriate decision maker on both port after maternal death. techniques for fetal evaluation as well as
accounts. More complex cases have the factors involved in deciding when to
arisen in which the father of the fetus CONCLUSION deliver were discussed. However, just
was not the next of kin of the deceased A case of pregnancy complicated by because a successful neonatal outcome
(New York Times, July 26, 1986, p 7; maternal brain death has been pre¬ can be arrived at in a case such as
San Francisco Examiner, July 13, sented. To our knowledge, it is the sec¬ this does not mean that prolonged
1986, p Bl; San Francisco Examiner, ond reported case in which prolonged somatic support ofthe mother should be
June 22,1986, p Bl; San Francisco Ex¬ somatic support of the mother resulted undertaken. Rather than proposing
aminer, June 19, 1986, p Bl). In these in the birth of a baby who survived, and strict guidelines, we believe that when
cases, requests by the father for somatic it represents the longest period such these rare cases appear, the decision
support over the objection of a woman's maternal support has been maintained. of whether to proceed with prolonged
next of kin have been upheld by the The medical and ethical issues involved cardiorespiratory support should be
courts. In most cases, it is ethically ap- with the prolonged support of a "beating based on the particulars of each case.
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