A brain-dead pregnant woman with prolonged somatic support and successful neonatal outcome: A grand rounds case with a detailed review of literature and ethical considerations

Abstract

There are increased reports in the medical literature of brain death during pregnancy. In these rare cases, the decision was either to consider discontinuing homeostatic support and mechanical ventilation with an understanding that the fetus then will also die, or to continue full support in an attempt to prolong pregnancy for the purpose of maintaining the fetus alive until maturity. We report the first case in the United Arab Emirates and in literature of somatic support that extended up to 110 days with the successful delivery of a viable fetus. A 35-year-old woman suffered intracranial hemorrhage during the 16th week of pregnancy that lead to brain death despite maximal surgical and medical management. Upon confirmation of this diagnosis, the patient received full ventilatory and homeostatic support required to prolong gestation and improve the survival prognosis of her fetus. The status of the patient was discussed in a multidisciplinary approach and with the full involvement of her family. Somatic support continued until the patient was 32 of weeks gestation. Obstetric complications of the patient were frequently assessed and managed. Lower segment cesarean section (LSCS) was then performed. A preterm male in breech presentation was delivered with an average weight of 750 gm, and an Apgar score of 6, 7, and 9 at 1, 5, and 10 minutes, respectively. Prolonging somatic support in a pregnant woman with brain death to allow fetal survival resulted in a successful outcome in terms of saving the life of the fetus. The results are consistent with previous published case reports in the literature on the appropriateness and safety of such a strategy that involved an intensive multidisciplinary approach. Despite being a tragedy, maternal death can represent an opportunity to save the life of the fetus and for organ donation. Consensus future recommendations that can guide the management of similar conditions may also be adapted, especially with the growing medical experience in this context.

Biophilosophical criticisms of brain death: The need for a new paradigm

“…Pregnant women with TBF have continued to gestate pregnancies for as many as 110 days to deliver viable fetuses [13]. To continue to claim such women are dead requires a new rationale since they are biologically very much alive.…”

Status of Baby Born to Brain-dead Mother: Ethical and Logical Issues

“…Brain death is a rare phenomenon (< 10% of all brain damage), and the incidence of brain death in pregnant women is even rarer. Suddaba et al determined that only 2.8% of all brain death cases occur in pregnant women (Said et al, 2013).…”

“…There is no global register of such patients, and literature provides information on thirty-seven cases registered between 1982 and 2019. Cases of brain death in pregnant women have been reported in the United States, Finland, Italy, Germany, Switzerland, Spain, Chile, Ireland, Great Britain, Brazil, Argentina, Poland, the United Arab Emirates, Croatia, and Japan (Bush et al, 2003;Burkle et al, 2003;Esmaeilzadeh et al, 2010;Heikkinen et al, 1985;Hussein et al, 2016;Lane et al, 2004;Nishimura et al, 2016;Souza et al, 2006;Wawrzyniak et al, 2015;Woderska et al, 2012;Said, et al, 2013;Wróżyńska, 2019). It is suspected that a large number of case reports have not been published due to therapeutic failure or that no diagnosis of brain death was made due to the inability to perform full diagnostics (e.g.…”

“…It is suspected that a large number of case reports have not been published due to therapeutic failure or that no diagnosis of brain death was made due to the inability to perform full diagnostics (e.g. apnoea tests) (Said, et al, 2013).…”

Guidelines for the management of the social and ethical challenges in brain death during pregnancy

“…However, the increasing number of published successful deliveries with favorable fetal outcomes does not provide firm conclusions because of the lack of published cases with unsuccessful support or unfavorable fetal outcome, consequently leading to publication bias . Leaving aside publication bias, some insights into how to manage these cases have been already cited in the literature, with successful corporeal support for 110 days as the most extended period published as a case study, and, more recently reported in the media in Brazil, 123 days . Long‐term follow up of the surviving children has been performed for 24 months in six cases, the longest being in Croatia for 36 months; however, longer follow‐ups are also needed to draw firm conclusions about the effects of such a delivery on the child.…”